Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Combined Anterior and Posterior Spinal Fusion Without CC/MCC

Facility

$34,967.14

Service Code	MS-DRG 455
Hospital Charge Code	275
Min. Negotiated Rate	$34,460.37
Max. Negotiated Rate	$34,967.14
Rate for Payer: Amerigroup Medicaid	$34,798.22
Rate for Payer: Iowa Total Care Managed Medicaid	$34,460.37
Rate for Payer: Molina Healthcare Managed Medicaid	$34,967.14

COMPATIBLE

Facility

$81.00

Service Code	CPT 86922
Hospital Charge Code	5850785
Hospital Revenue Code	302
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$72.90
Rate for Payer: Aetna of IA Commercial	$72.90
Rate for Payer: Aetna of IA Medical Rental Products	$72.90
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$60.75
Rate for Payer: Medical Associates Commercial	$60.75
Rate for Payer: Midlands Choice Commercial	$56.70
Rate for Payer: United Healthcare Commercial	$72.90

COMPATIBLE

Facility

$81.00

Service Code	CPT 86922
Hospital Charge Code	5850785
Hospital Revenue Code	302
Min. Negotiated Rate	$40.48
Max. Negotiated Rate	$107.07
Rate for Payer: Aetna of IA Commercial	$72.90
Rate for Payer: Aetna of IA Medical Rental Products	$72.90
Rate for Payer: Aetna of IA Medicare	$46.17
Rate for Payer: Amerigroup Medicaid	$40.88
Rate for Payer: Amerigroup Medicare	$40.90
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$60.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$40.50
Rate for Payer: Iowa Total Care Managed Medicaid	$40.48
Rate for Payer: Medical Associates Commercial	$60.75
Rate for Payer: Medical Associates Managed Medicare	$40.50
Rate for Payer: Midlands Choice Commercial	$56.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.11
Rate for Payer: Molina Healthcare Managed Medicare	$41.08
Rate for Payer: Oscar Health of IA Commercial	$60.75
Rate for Payer: Partners Health Alliance Commercial	$60.75
Rate for Payer: United Healthcare Commercial	$72.90
Rate for Payer: United Healthcare Managed Medicare	$47.79
Rate for Payer: Wellmark IA HMO	$97.34
Rate for Payer: Wellmark IA PPO	$107.07

Complement C3 DMCL

Facility

$98.00

Service Code	CPT 86160
Hospital Charge Code	8037514
Hospital Revenue Code	302
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: United Healthcare Commercial	$88.20

Complement C3 DMCL

Facility

$98.00

Service Code	CPT 86160
Hospital Charge Code	8037514
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Aetna of IA Medicare	$55.86
Rate for Payer: Amerigroup Medicaid	$49.46
Rate for Payer: Amerigroup Medicare	$49.49
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.00
Rate for Payer: Iowa Total Care Managed Medicaid	$48.98
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Medical Associates Managed Medicare	$49.00
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: Molina Healthcare Managed Medicaid	$49.74
Rate for Payer: Molina Healthcare Managed Medicare	$49.71
Rate for Payer: Oscar Health of IA Commercial	$73.50
Rate for Payer: Partners Health Alliance Commercial	$73.50
Rate for Payer: United Healthcare Commercial	$88.20
Rate for Payer: United Healthcare Managed Medicare	$57.82
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Complement C4 DMCL

Facility

$98.00

Service Code	CPT 86160
Hospital Charge Code	8037515
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Aetna of IA Medicare	$55.86
Rate for Payer: Amerigroup Medicaid	$49.46
Rate for Payer: Amerigroup Medicare	$49.49
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.00
Rate for Payer: Iowa Total Care Managed Medicaid	$48.98
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Medical Associates Managed Medicare	$49.00
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: Molina Healthcare Managed Medicaid	$49.74
Rate for Payer: Molina Healthcare Managed Medicare	$49.71
Rate for Payer: Oscar Health of IA Commercial	$73.50
Rate for Payer: Partners Health Alliance Commercial	$73.50
Rate for Payer: United Healthcare Commercial	$88.20
Rate for Payer: United Healthcare Managed Medicare	$57.82
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Complement C4 DMCL

Facility

$98.00

Service Code	CPT 86160
Hospital Charge Code	8037515
Hospital Revenue Code	302
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: United Healthcare Commercial	$88.20

Complete Blood Count w Man Diff DMCL

Facility

$66.00

Service Code	CPT 85027
Hospital Charge Code	8037516
Hospital Revenue Code	305
Min. Negotiated Rate	$32.86
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	$33.31
Rate for Payer: Amerigroup Medicare	$33.33
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	$33.00
Rate for Payer: Iowa Total Care Managed Medicaid	$32.99
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Medical Associates Managed Medicare	$33.00
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: Molina Healthcare Managed Medicaid	$33.50
Rate for Payer: Molina Healthcare Managed Medicare	$33.48
Rate for Payer: Oscar Health of IA Commercial	$49.50
Rate for Payer: Partners Health Alliance Commercial	$49.50
Rate for Payer: United Healthcare Commercial	$59.40
Rate for Payer: United Healthcare Managed Medicare	$38.94
Rate for Payer: Wellmark IA HMO	$32.86
Rate for Payer: Wellmark IA PPO	$36.15

Complete Blood Count w Man Diff DMCL

Facility

$66.00

Service Code	CPT 85027
Hospital Charge Code	8037516
Hospital Revenue Code	305
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

Complicated Peptic Ulcer With CC

Facility

$7,809.95

Service Code	MS-DRG 381
Hospital Charge Code	222
Min. Negotiated Rate	$7,696.77
Max. Negotiated Rate	$7,809.95
Rate for Payer: Amerigroup Medicaid	$7,772.23
Rate for Payer: Iowa Total Care Managed Medicaid	$7,696.77
Rate for Payer: Molina Healthcare Managed Medicaid	$7,809.95

Complicated Peptic Ulcer With MCC

Facility

$14,224.26

Service Code	MS-DRG 380
Hospital Charge Code	221
Min. Negotiated Rate	$14,018.12
Max. Negotiated Rate	$14,224.26
Rate for Payer: Amerigroup Medicaid	$14,155.55
Rate for Payer: Iowa Total Care Managed Medicaid	$14,018.12
Rate for Payer: Molina Healthcare Managed Medicaid	$14,224.26

Complicated Peptic Ulcer Without CC/MCC

Facility

$7,078.67

Service Code	MS-DRG 382
Hospital Charge Code	223
Min. Negotiated Rate	$6,976.08
Max. Negotiated Rate	$7,078.67
Rate for Payer: Amerigroup Medicaid	$7,044.47
Rate for Payer: Iowa Total Care Managed Medicaid	$6,976.08
Rate for Payer: Molina Healthcare Managed Medicaid	$7,078.67

Complications of Treatment With CC

Facility

$9,673.13

Service Code	MS-DRG 920
Hospital Charge Code	638
Min. Negotiated Rate	$9,532.94
Max. Negotiated Rate	$9,673.13
Rate for Payer: Amerigroup Medicaid	$9,626.40
Rate for Payer: Iowa Total Care Managed Medicaid	$9,532.94
Rate for Payer: Molina Healthcare Managed Medicaid	$9,673.13

Complications of Treatment With MCC

Facility

$12,469.36

Service Code	MS-DRG 919
Hospital Charge Code	637
Min. Negotiated Rate	$12,288.64
Max. Negotiated Rate	$12,469.36
Rate for Payer: Amerigroup Medicaid	$12,409.12
Rate for Payer: Iowa Total Care Managed Medicaid	$12,288.64
Rate for Payer: Molina Healthcare Managed Medicaid	$12,469.36

Complications of Treatment Without CC/MCC

Facility

$4,681.06

Service Code	MS-DRG 921
Hospital Charge Code	639
Min. Negotiated Rate	$4,613.22
Max. Negotiated Rate	$4,681.06
Rate for Payer: Amerigroup Medicaid	$4,658.44
Rate for Payer: Iowa Total Care Managed Medicaid	$4,613.22
Rate for Payer: Molina Healthcare Managed Medicaid	$4,681.06

COMPOSITE CORKSCREW 5.5 SUTURE ANCHOR

Facility

$549.00

Service Code	CPT C1713
Hospital Charge Code	8026044
Hospital Revenue Code	278
Min. Negotiated Rate	$274.39
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna of IA Commercial	$494.10
Rate for Payer: Aetna of IA Medical Rental Products	$494.10
Rate for Payer: Aetna of IA Medicare	$312.93
Rate for Payer: Amerigroup Medicaid	$277.08
Rate for Payer: Amerigroup Medicare	$277.24
Rate for Payer: Cash Price	$439.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$411.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$274.50
Rate for Payer: Iowa Total Care Managed Medicaid	$274.39
Rate for Payer: Medical Associates Commercial	$411.75
Rate for Payer: Medical Associates Managed Medicare	$274.50
Rate for Payer: Midlands Choice Commercial	$384.30
Rate for Payer: Molina Healthcare Managed Medicaid	$278.62
Rate for Payer: Molina Healthcare Managed Medicare	$278.45
Rate for Payer: Oscar Health of IA Commercial	$411.75
Rate for Payer: Partners Health Alliance Commercial	$411.75
Rate for Payer: United Healthcare Commercial	$494.10
Rate for Payer: United Healthcare Managed Medicare	$323.91

COMPOSITE CORKSCREW 5.5 SUTURE ANCHOR

Facility

$549.00

Service Code	CPT C1713
Hospital Charge Code	8026044
Hospital Revenue Code	278
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna of IA Commercial	$494.10
Rate for Payer: Aetna of IA Medical Rental Products	$494.10
Rate for Payer: Cash Price	$439.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$411.75
Rate for Payer: Medical Associates Commercial	$411.75
Rate for Payer: Midlands Choice Commercial	$384.30
Rate for Payer: United Healthcare Commercial	$494.10

COMPREHENSIVE METABOLIC PANEL

Facility

$198.00

Service Code	CPT 80053
Hospital Charge Code	633709
Hospital Revenue Code	301
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

COMPREHENSIVE METABOLIC PANEL

Facility

$198.00

Service Code	CPT 80053
Hospital Charge Code	633709
Hospital Revenue Code	301
Min. Negotiated Rate	$52.08
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$99.93
Rate for Payer: Amerigroup Medicare	$99.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.00
Rate for Payer: Iowa Total Care Managed Medicaid	$98.96
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$99.00
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$100.48
Rate for Payer: Molina Healthcare Managed Medicare	$100.43
Rate for Payer: Oscar Health of IA Commercial	$148.50
Rate for Payer: Partners Health Alliance Commercial	$148.50
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82
Rate for Payer: Wellmark IA HMO	$52.08
Rate for Payer: Wellmark IA PPO	$57.29

COMPUTER XM OK

Facility

$73.00

Service Code	CPT 86920
Hospital Charge Code	6306782
Hospital Revenue Code	302
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: United Healthcare Commercial	$65.70

COMPUTER XM OK

Facility

$73.00

Service Code	CPT 86920
Hospital Charge Code	6306782
Hospital Revenue Code	302
Min. Negotiated Rate	$36.49
Max. Negotiated Rate	$107.07
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Aetna of IA Medicare	$41.61
Rate for Payer: Amerigroup Medicaid	$36.84
Rate for Payer: Amerigroup Medicare	$36.86
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.50
Rate for Payer: Iowa Total Care Managed Medicaid	$36.49
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Medical Associates Managed Medicare	$36.50
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: Molina Healthcare Managed Medicaid	$37.05
Rate for Payer: Molina Healthcare Managed Medicare	$37.03
Rate for Payer: Oscar Health of IA Commercial	$54.75
Rate for Payer: Partners Health Alliance Commercial	$54.75
Rate for Payer: United Healthcare Commercial	$65.70
Rate for Payer: United Healthcare Managed Medicare	$43.07
Rate for Payer: Wellmark IA HMO	$97.34
Rate for Payer: Wellmark IA PPO	$107.07

CONCELLTRATE 100 2.5CC JAR

Facility

$2,205.00

Service Code	CPT C1713
Hospital Charge Code	8463706
Hospital Revenue Code	278
Min. Negotiated Rate	$1,543.50
Max. Negotiated Rate	$1,984.50
Rate for Payer: Aetna of IA Commercial	$1,984.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,984.50
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,653.75
Rate for Payer: Medical Associates Commercial	$1,653.75
Rate for Payer: Midlands Choice Commercial	$1,543.50
Rate for Payer: United Healthcare Commercial	$1,984.50

CONCELLTRATE 100 2.5CC JAR

Facility

$2,205.00

Service Code	CPT C1713
Hospital Charge Code	8463706
Hospital Revenue Code	278
Min. Negotiated Rate	$1,102.06
Max. Negotiated Rate	$1,984.50
Rate for Payer: Aetna of IA Commercial	$1,984.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,984.50
Rate for Payer: Aetna of IA Medicare	$1,256.85
Rate for Payer: Amerigroup Medicaid	$1,112.86
Rate for Payer: Amerigroup Medicare	$1,113.52
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,653.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,102.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,102.06
Rate for Payer: Medical Associates Commercial	$1,653.75
Rate for Payer: Medical Associates Managed Medicare	$1,102.50
Rate for Payer: Midlands Choice Commercial	$1,543.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,119.04
Rate for Payer: Molina Healthcare Managed Medicare	$1,118.38
Rate for Payer: Oscar Health of IA Commercial	$1,653.75
Rate for Payer: Partners Health Alliance Commercial	$1,653.75
Rate for Payer: United Healthcare Commercial	$1,984.50
Rate for Payer: United Healthcare Managed Medicare	$1,300.95

CONCELLTRATE 100 5.0CC JAR

Facility

$3,069.00

Service Code	CPT C1713
Hospital Charge Code	8748485
Hospital Revenue Code	278
Min. Negotiated Rate	$2,148.30
Max. Negotiated Rate	$2,762.10
Rate for Payer: Aetna of IA Commercial	$2,762.10
Rate for Payer: Aetna of IA Medical Rental Products	$2,762.10
Rate for Payer: Cash Price	$2,455.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,301.75
Rate for Payer: Medical Associates Commercial	$2,301.75
Rate for Payer: Midlands Choice Commercial	$2,148.30
Rate for Payer: United Healthcare Commercial	$2,762.10

CONCELLTRATE 100 5.0CC JAR

Facility

$3,069.00

Service Code	CPT C1713
Hospital Charge Code	8748485
Hospital Revenue Code	278
Min. Negotiated Rate	$1,533.89
Max. Negotiated Rate	$2,762.10
Rate for Payer: Aetna of IA Commercial	$2,762.10
Rate for Payer: Aetna of IA Medical Rental Products	$2,762.10
Rate for Payer: Aetna of IA Medicare	$1,749.33
Rate for Payer: Amerigroup Medicaid	$1,548.92
Rate for Payer: Amerigroup Medicare	$1,549.84
Rate for Payer: Cash Price	$2,455.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,301.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,534.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,533.89
Rate for Payer: Medical Associates Commercial	$2,301.75
Rate for Payer: Medical Associates Managed Medicare	$1,534.50
Rate for Payer: Midlands Choice Commercial	$2,148.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1,557.52
Rate for Payer: Molina Healthcare Managed Medicare	$1,556.60
Rate for Payer: Oscar Health of IA Commercial	$2,301.75
Rate for Payer: Partners Health Alliance Commercial	$2,301.75
Rate for Payer: United Healthcare Commercial	$2,762.10
Rate for Payer: United Healthcare Managed Medicare	$1,810.71

Know your out-of-pocket cost for care.

All Charges