Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Spinal injection- lumbar w/o imaging

Professional

Both

$517.00

Service Code	CPT 62322
Hospital Charge Code	8037762
Hospital Revenue Code	975
Min. Negotiated Rate	$142.88
Max. Negotiated Rate	$387.75
Rate for Payer: Amerigroup Medicaid	$144.28
Rate for Payer: Cash Price	$413.60
Rate for Payer: Cash Price	$413.60
Rate for Payer: Iowa Total Care Managed Medicaid	$142.88
Rate for Payer: Medical Associates Commercial	$387.75
Rate for Payer: Midlands Choice Commercial	$361.90
Rate for Payer: Molina Healthcare Managed Medicaid	$143.58
Rate for Payer: Partners Health Alliance Commercial	$387.75
Rate for Payer: United Healthcare Commercial	$227.78
Rate for Payer: Wellmark IA HMO WHPI	$254.30
Rate for Payer: Wellmark IA PPO	$299.20

SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS

Facility

$24,595.84

Service Code	MSDRG 029
Min. Negotiated Rate	$24,239.37
Max. Negotiated Rate	$24,595.84
Rate for Payer: Amerigroup Medicaid	$24,477.01
Rate for Payer: Iowa Total Care Managed Medicaid	$24,239.37
Rate for Payer: Molina Healthcare Managed Medicaid	$24,595.84

SPINAL PROCEDURES WITH MCC

Facility

$41,683.67

Service Code	MSDRG 028
Min. Negotiated Rate	$41,079.54
Max. Negotiated Rate	$41,683.67
Rate for Payer: Amerigroup Medicaid	$41,482.28
Rate for Payer: Iowa Total Care Managed Medicaid	$41,079.54
Rate for Payer: Molina Healthcare Managed Medicaid	$41,683.67

SPINAL PROCEDURES WITHOUT CC/MCC

Facility

$20,899.26

Service Code	MSDRG 030
Min. Negotiated Rate	$20,596.36
Max. Negotiated Rate	$20,899.26
Rate for Payer: Amerigroup Medicaid	$20,798.29
Rate for Payer: Iowa Total Care Managed Medicaid	$20,596.36
Rate for Payer: Molina Healthcare Managed Medicaid	$20,899.26

SPINAL PUNCTURE LUMBAR

Professional

Both

$463.00

Service Code	CPT 62270
Hospital Charge Code	8059050
Hospital Revenue Code	975
Min. Negotiated Rate	$113.34
Max. Negotiated Rate	$347.25
Rate for Payer: Amerigroup Medicaid	$114.45
Rate for Payer: Cash Price	$370.40
Rate for Payer: Cash Price	$370.40
Rate for Payer: Iowa Total Care Managed Medicaid	$113.34
Rate for Payer: Medical Associates Commercial	$347.25
Rate for Payer: Midlands Choice Commercial	$324.10
Rate for Payer: Molina Healthcare Managed Medicaid	$113.90
Rate for Payer: Partners Health Alliance Commercial	$347.25
Rate for Payer: United Healthcare Commercial	$210.02
Rate for Payer: Wellmark IA HMO WHPI	$275.00
Rate for Payer: Wellmark IA PPO	$323.50

SPINAL PUNCTURE LUMBAR

Facility

$406.00

Service Code	CPT 62270
Hospital Charge Code	8059050
Hospital Revenue Code	964
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$1,679.15
Rate for Payer: Aetna of IA Commercial	$365.40
Rate for Payer: Aetna of IA Medical Rental Products	$365.40
Rate for Payer: Aetna of IA Medicare	$231.42
Rate for Payer: Amerigroup Medicaid	$234.18
Rate for Payer: Amerigroup Medicare	$184.53
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cash Price	$324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$304.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$182.70
Rate for Payer: Iowa Total Care Managed Medicaid	$231.91
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Medical Associates Managed Medicare	$182.70
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: Molina Healthcare Managed Medicaid	$235.32
Rate for Payer: Partners Health Alliance Commercial	$210.10
Rate for Payer: United Healthcare Commercial	$365.40
Rate for Payer: Wellmark IA HMO WHPI	$1,524.35
Rate for Payer: Wellmark IA PPO	$1,679.15

SPINAL PUNCTURE LUMBAR

Facility

$406.00

Service Code	CPT 62270
Hospital Charge Code	8059050
Hospital Revenue Code	964
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of IA Commercial	$365.40
Rate for Payer: Aetna of IA Medical Rental Products	$365.40
Rate for Payer: Cash Price	$324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$304.50
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: United Healthcare Commercial	$365.40

Spinal Tap Procedure

Facility

$602.00

Service Code	CPT 62270
Hospital Charge Code	8060782
Hospital Revenue Code	761
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$1,679.15
Rate for Payer: Aetna of IA Commercial	$541.80
Rate for Payer: Aetna of IA Medical Rental Products	$541.80
Rate for Payer: Aetna of IA Medicare	$343.14
Rate for Payer: Amerigroup Medicaid	$347.23
Rate for Payer: Amerigroup Medicare	$273.61
Rate for Payer: Cash Price	$481.60
Rate for Payer: Cash Price	$481.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$451.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$270.90
Rate for Payer: Iowa Total Care Managed Medicaid	$343.86
Rate for Payer: Medical Associates Commercial	$451.50
Rate for Payer: Medical Associates Managed Medicare	$270.90
Rate for Payer: Midlands Choice Commercial	$421.40
Rate for Payer: Molina Healthcare Managed Medicaid	$348.92
Rate for Payer: Partners Health Alliance Commercial	$311.54
Rate for Payer: United Healthcare Commercial	$541.80
Rate for Payer: United Healthcare Managed Medicare	$355.18
Rate for Payer: Wellmark IA HMO WHPI	$1,524.35
Rate for Payer: Wellmark IA PPO	$1,679.15

Spinal Tap Procedure

Facility

$602.00

Service Code	CPT 62270
Hospital Charge Code	8060782
Hospital Revenue Code	761
Min. Negotiated Rate	$421.40
Max. Negotiated Rate	$541.80
Rate for Payer: Aetna of IA Commercial	$541.80
Rate for Payer: Aetna of IA Medical Rental Products	$541.80
Rate for Payer: Cash Price	$481.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$451.50
Rate for Payer: Medical Associates Commercial	$451.50
Rate for Payer: Midlands Choice Commercial	$421.40
Rate for Payer: United Healthcare Commercial	$541.80

spironolactone 100 mg Tab [VDMC]

Facility

$1.60

Service Code	HCPCS A9270
Hospital Charge Code	10422027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of IA Commercial	$1.44
Rate for Payer: Aetna of IA Medical Rental Products	$1.44
Rate for Payer: Aetna of IA Medicare	$0.91
Rate for Payer: Amerigroup Medicaid	$0.92
Rate for Payer: Amerigroup Medicare	$0.73
Rate for Payer: Cash Price	$1.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.72
Rate for Payer: Iowa Total Care Managed Medicaid	$0.91
Rate for Payer: Medical Associates Commercial	$1.20
Rate for Payer: Medical Associates Managed Medicare	$0.72
Rate for Payer: Midlands Choice Commercial	$1.12
Rate for Payer: Molina Healthcare Managed Medicaid	$0.93
Rate for Payer: Partners Health Alliance Commercial	$0.83
Rate for Payer: United Healthcare Commercial	$1.44
Rate for Payer: United Healthcare Managed Medicare	$0.94

spironolactone 100 mg Tab [VDMC]

Facility

$1.60

Service Code	HCPCS A9270
Hospital Charge Code	10422027
Hospital Revenue Code	259
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of IA Commercial	$1.44
Rate for Payer: Aetna of IA Medical Rental Products	$1.44
Rate for Payer: Cash Price	$1.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.20
Rate for Payer: Medical Associates Commercial	$1.20
Rate for Payer: Midlands Choice Commercial	$1.12
Rate for Payer: United Healthcare Commercial	$1.44

spironolactone 25 mg Tab [VDMC]

Facility

$1.44

Service Code	HCPCS A9270
Hospital Charge Code	10422096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Aetna of IA Medicare	$0.82
Rate for Payer: Amerigroup Medicaid	$0.83
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.08
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.65
Rate for Payer: Iowa Total Care Managed Medicaid	$0.82
Rate for Payer: Medical Associates Commercial	$1.08
Rate for Payer: Medical Associates Managed Medicare	$0.65
Rate for Payer: Midlands Choice Commercial	$1.01
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Partners Health Alliance Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Managed Medicare	$0.85

spironolactone 25 mg Tab [VDMC]

Facility

$1.44

Service Code	HCPCS A9270
Hospital Charge Code	10422096
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.08
Rate for Payer: Medical Associates Commercial	$1.08
Rate for Payer: Midlands Choice Commercial	$1.01
Rate for Payer: United Healthcare Commercial	$1.29

SPLENIC PROCEDURES WITH CC

Facility

$18,496.42

Service Code	MSDRG 800
Min. Negotiated Rate	$18,228.35
Max. Negotiated Rate	$18,496.42
Rate for Payer: Amerigroup Medicaid	$18,407.06
Rate for Payer: Iowa Total Care Managed Medicaid	$18,228.35
Rate for Payer: Molina Healthcare Managed Medicaid	$18,496.42

SPLENIC PROCEDURES WITH MCC

Facility

$37,733.74

Service Code	MSDRG 799
Min. Negotiated Rate	$37,186.86
Max. Negotiated Rate	$37,733.74
Rate for Payer: Amerigroup Medicaid	$37,551.44
Rate for Payer: Iowa Total Care Managed Medicaid	$37,186.86
Rate for Payer: Molina Healthcare Managed Medicaid	$37,733.74

SPLENIC PROCEDURES WITHOUT CC/MCC

Facility

$15,760.30

Service Code	MSDRG 801
Min. Negotiated Rate	$15,531.88
Max. Negotiated Rate	$15,760.30
Rate for Payer: Amerigroup Medicaid	$15,684.16
Rate for Payer: Iowa Total Care Managed Medicaid	$15,531.88
Rate for Payer: Molina Healthcare Managed Medicaid	$15,760.30

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC

Facility

$9,028.08

Service Code	MSDRG 537
Min. Negotiated Rate	$8,897.24
Max. Negotiated Rate	$9,028.08
Rate for Payer: Amerigroup Medicaid	$8,984.47
Rate for Payer: Iowa Total Care Managed Medicaid	$8,897.24
Rate for Payer: Molina Healthcare Managed Medicaid	$9,028.08

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC

Facility

$8,122.80

Service Code	MSDRG 538
Min. Negotiated Rate	$8,005.07
Max. Negotiated Rate	$8,122.80
Rate for Payer: Amerigroup Medicaid	$8,083.55
Rate for Payer: Iowa Total Care Managed Medicaid	$8,005.07
Rate for Payer: Molina Healthcare Managed Medicaid	$8,122.80

SPRAVATO OBSERVATION

Professional

Both

$500.00

Service Code	CPT 99213
Hospital Charge Code	8829628
Hospital Revenue Code	983
Min. Negotiated Rate	$44.09
Max. Negotiated Rate	$375.00
Rate for Payer: Amerigroup Medicaid	$44.53
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Iowa Total Care Managed Medicaid	$44.09
Rate for Payer: Medical Associates Commercial	$375.00
Rate for Payer: Midlands Choice Commercial	$350.00
Rate for Payer: Molina Healthcare Managed Medicaid	$44.31
Rate for Payer: Partners Health Alliance Commercial	$375.00
Rate for Payer: United Healthcare Commercial	$81.57
Rate for Payer: Wellmark IA HMO WHPI	$129.90
Rate for Payer: Wellmark IA PPO	$129.90

SQ/IM INJECTIONS ADMIN

Facility

$66.00

Service Code	CPT 96372
Hospital Charge Code	7984745
Hospital Revenue Code	761
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Aetna of IA Medicare	$37.62
Rate for Payer: Amerigroup Medicaid	$38.07
Rate for Payer: Amerigroup Medicare	$30.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.70
Rate for Payer: Iowa Total Care Managed Medicaid	$37.70
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Medical Associates Managed Medicare	$29.70
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: Molina Healthcare Managed Medicaid	$38.25
Rate for Payer: Partners Health Alliance Commercial	$34.16
Rate for Payer: United Healthcare Commercial	$59.40
Rate for Payer: United Healthcare Managed Medicare	$38.94
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

SQ/IM INJECTIONS ADMIN

Facility

$66.00

Service Code	CPT 96372
Hospital Charge Code	7984745
Hospital Revenue Code	761
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: United Healthcare Commercial	$59.40

STANDARD MPJ PLATE, RIGHT

Facility

$1,914.00

Service Code	HCPCS C1713
Hospital Charge Code	8948786
Hospital Revenue Code	278
Min. Negotiated Rate	$861.30
Max. Negotiated Rate	$1,722.60
Rate for Payer: Aetna of IA Commercial	$1,722.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,722.60
Rate for Payer: Aetna of IA Medicare	$1,090.98
Rate for Payer: Amerigroup Medicaid	$1,104.00
Rate for Payer: Amerigroup Medicare	$869.91
Rate for Payer: Cash Price	$1,531.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,435.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$861.30
Rate for Payer: Iowa Total Care Managed Medicaid	$1,093.28
Rate for Payer: Medical Associates Commercial	$1,435.50
Rate for Payer: Medical Associates Managed Medicare	$861.30
Rate for Payer: Midlands Choice Commercial	$1,339.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,109.35
Rate for Payer: Partners Health Alliance Commercial	$990.50
Rate for Payer: United Healthcare Commercial	$1,722.60
Rate for Payer: United Healthcare Managed Medicare	$1,129.26

STANDARD MPJ PLATE, RIGHT

Facility

$1,914.00

Service Code	HCPCS C1713
Hospital Charge Code	8948786
Hospital Revenue Code	278
Min. Negotiated Rate	$1,339.80
Max. Negotiated Rate	$1,722.60
Rate for Payer: Aetna of IA Commercial	$1,722.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,722.60
Rate for Payer: Cash Price	$1,531.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,435.50
Rate for Payer: Medical Associates Commercial	$1,435.50
Rate for Payer: Midlands Choice Commercial	$1,339.80
Rate for Payer: United Healthcare Commercial	$1,722.60

STAPLER GIA 60 2.5 MULTIFIRE DISPOSABLE

Facility

$484.00

Hospital Charge Code	8046475
Hospital Revenue Code	272
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$435.60
Rate for Payer: Aetna of IA Commercial	$435.60
Rate for Payer: Aetna of IA Medical Rental Products	$435.60
Rate for Payer: Aetna of IA Medicare	$275.88
Rate for Payer: Amerigroup Medicaid	$279.17
Rate for Payer: Amerigroup Medicare	$219.98
Rate for Payer: Cash Price	$387.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$363.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$217.80
Rate for Payer: Iowa Total Care Managed Medicaid	$276.46
Rate for Payer: Medical Associates Commercial	$363.00
Rate for Payer: Medical Associates Managed Medicare	$217.80
Rate for Payer: Midlands Choice Commercial	$338.80
Rate for Payer: Molina Healthcare Managed Medicaid	$280.53
Rate for Payer: Partners Health Alliance Commercial	$250.47
Rate for Payer: United Healthcare Commercial	$435.60
Rate for Payer: United Healthcare Managed Medicare	$285.56

STAPLER GIA 60 2.5 MULTIFIRE DISPOSABLE

Facility

$484.00

Hospital Charge Code	8046475
Hospital Revenue Code	272
Min. Negotiated Rate	$338.80
Max. Negotiated Rate	$435.60
Rate for Payer: Aetna of IA Commercial	$435.60
Rate for Payer: Aetna of IA Medical Rental Products	$435.60
Rate for Payer: Cash Price	$387.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$363.00
Rate for Payer: Medical Associates Commercial	$363.00
Rate for Payer: Midlands Choice Commercial	$338.80
Rate for Payer: United Healthcare Commercial	$435.60

Know your out-of-pocket cost for care.

All Charges