Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Ceruloplasmin DMCL

Facility

$139.00

Service Code	CPT 82390
Hospital Charge Code	8037510
Hospital Revenue Code	301
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

CERUMEN REMOVAL

Professional

Both

$132.00

Service Code	CPT 69210
Hospital Charge Code	7982759
Hospital Revenue Code	981
Min. Negotiated Rate	$29.54
Max. Negotiated Rate	$25,263.00
Rate for Payer: Aetna of IA Medicare	$29.54
Rate for Payer: Amerigroup Medicaid	$30.54
Rate for Payer: Cash Price	$105.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.45
Rate for Payer: Iowa Total Care Managed Medicaid	$30.13
Rate for Payer: Medical Associates Commercial	$53.17
Rate for Payer: Medical Associates Managed Medicare	$29.54
Rate for Payer: Midlands Choice Commercial	$25,263.00
Rate for Payer: Oscar Health of IA Commercial	$51.10
Rate for Payer: Partners Health Alliance Commercial	$44.31

Cervical Spinal Fusion With CC

Facility

$23,571.60

Service Code	MS-DRG 472
Hospital Charge Code	292
Min. Negotiated Rate	$23,229.98
Max. Negotiated Rate	$23,571.60
Rate for Payer: Amerigroup Medicaid	$23,457.72
Rate for Payer: Iowa Total Care Managed Medicaid	$23,229.98
Rate for Payer: Molina Healthcare Managed Medicaid	$23,571.60

Cervical Spinal Fusion With MCC

Facility

$40,149.18

Service Code	MS-DRG 471
Hospital Charge Code	291
Min. Negotiated Rate	$39,567.31
Max. Negotiated Rate	$40,149.18
Rate for Payer: Amerigroup Medicaid	$39,955.22
Rate for Payer: Iowa Total Care Managed Medicaid	$39,567.31
Rate for Payer: Molina Healthcare Managed Medicaid	$40,149.18

Cervical Spinal Fusion Without CC/MCC

Facility

$18,371.85

Service Code	MS-DRG 473
Hospital Charge Code	293
Min. Negotiated Rate	$18,105.59
Max. Negotiated Rate	$18,371.85
Rate for Payer: Amerigroup Medicaid	$18,283.10
Rate for Payer: Iowa Total Care Managed Medicaid	$18,105.59
Rate for Payer: Molina Healthcare Managed Medicaid	$18,371.85

Cesarean Section Without Sterilization With CC

Facility

$9,602.26

Service Code	MS-DRG 787
Hospital Charge Code	529
Min. Negotiated Rate	$9,463.10
Max. Negotiated Rate	$9,602.26
Rate for Payer: Amerigroup Medicaid	$9,555.88
Rate for Payer: Iowa Total Care Managed Medicaid	$9,463.10
Rate for Payer: Molina Healthcare Managed Medicaid	$9,602.26

Cesarean Section Without Sterilization With MCC

Facility

$11,203.62

Service Code	MS-DRG 786
Hospital Charge Code	528
Min. Negotiated Rate	$11,041.24
Max. Negotiated Rate	$11,203.62
Rate for Payer: Amerigroup Medicaid	$11,149.49
Rate for Payer: Iowa Total Care Managed Medicaid	$11,041.24
Rate for Payer: Molina Healthcare Managed Medicaid	$11,203.62

Cesarean Section Without Sterilization Without CC/MCC

Facility

$8,554.05

Service Code	MS-DRG 788
Hospital Charge Code	530
Min. Negotiated Rate	$8,430.08
Max. Negotiated Rate	$8,554.05
Rate for Payer: Amerigroup Medicaid	$8,512.72
Rate for Payer: Iowa Total Care Managed Medicaid	$8,430.08
Rate for Payer: Molina Healthcare Managed Medicaid	$8,554.05

Cesarean Section With Sterilization With CC

Facility

$9,088.49

Service Code	MS-DRG 784
Hospital Charge Code	526
Min. Negotiated Rate	$8,956.77
Max. Negotiated Rate	$9,088.49
Rate for Payer: Amerigroup Medicaid	$9,044.58
Rate for Payer: Iowa Total Care Managed Medicaid	$8,956.77
Rate for Payer: Molina Healthcare Managed Medicaid	$9,088.49

Cesarean Section With Sterilization With MCC

Facility

$11,362.09

Service Code	MS-DRG 783
Hospital Charge Code	525
Min. Negotiated Rate	$11,197.42
Max. Negotiated Rate	$11,362.09
Rate for Payer: Amerigroup Medicaid	$11,307.20
Rate for Payer: Iowa Total Care Managed Medicaid	$11,197.42
Rate for Payer: Molina Healthcare Managed Medicaid	$11,362.09

Cesarean Section With Sterilization Without CC/MCC

Facility

$8,057.98

Service Code	MS-DRG 785
Hospital Charge Code	527
Min. Negotiated Rate	$7,941.20
Max. Negotiated Rate	$8,057.98
Rate for Payer: Amerigroup Medicaid	$8,019.05
Rate for Payer: Iowa Total Care Managed Medicaid	$7,941.20
Rate for Payer: Molina Healthcare Managed Medicaid	$8,057.98

cetirizine 10 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10376958
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of IA Commercial	$1.40
Rate for Payer: Aetna of IA Medical Rental Products	$1.40
Rate for Payer: Aetna of IA Medicare	$0.89
Rate for Payer: Amerigroup Medicaid	$0.79
Rate for Payer: Amerigroup Medicare	$0.79
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.78
Rate for Payer: Iowa Total Care Managed Medicaid	$0.78
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Medical Associates Managed Medicare	$0.78
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: Molina Healthcare Managed Medicaid	$0.79
Rate for Payer: Molina Healthcare Managed Medicare	$0.79
Rate for Payer: Oscar Health of IA Commercial	$1.17
Rate for Payer: Partners Health Alliance Commercial	$1.17
Rate for Payer: United Healthcare Commercial	$1.40
Rate for Payer: United Healthcare Managed Medicare	$0.92

cetirizine 10 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10376958
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of IA Commercial	$1.40
Rate for Payer: Aetna of IA Medical Rental Products	$1.40
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: United Healthcare Commercial	$1.40

cetirizine 5mg/5ml 120 ml bottle [VDMC]

Facility

$15.20

Service Code	HCPCS A9270
Hospital Charge Code	16005974
Hospital Revenue Code	259
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$13.68
Rate for Payer: Aetna of IA Commercial	$13.68
Rate for Payer: Aetna of IA Medical Rental Products	$13.68
Rate for Payer: Aetna of IA Medicare	$8.66
Rate for Payer: Amerigroup Medicaid	$7.67
Rate for Payer: Amerigroup Medicare	$7.68
Rate for Payer: Cash Price	$12.16
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.60
Rate for Payer: Iowa Total Care Managed Medicaid	$7.60
Rate for Payer: Medical Associates Commercial	$11.40
Rate for Payer: Medical Associates Managed Medicare	$7.60
Rate for Payer: Midlands Choice Commercial	$10.64
Rate for Payer: Molina Healthcare Managed Medicaid	$7.71
Rate for Payer: Molina Healthcare Managed Medicare	$7.71
Rate for Payer: Oscar Health of IA Commercial	$11.40
Rate for Payer: Partners Health Alliance Commercial	$11.40
Rate for Payer: United Healthcare Commercial	$13.68
Rate for Payer: United Healthcare Managed Medicare	$8.97

cetirizine 5mg/5ml 120 ml bottle [VDMC]

Facility

$15.20

Service Code	HCPCS A9270
Hospital Charge Code	16005974
Hospital Revenue Code	259
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$13.68
Rate for Payer: Aetna of IA Commercial	$13.68
Rate for Payer: Aetna of IA Medical Rental Products	$13.68
Rate for Payer: Cash Price	$12.16
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.40
Rate for Payer: Medical Associates Commercial	$11.40
Rate for Payer: Midlands Choice Commercial	$10.64
Rate for Payer: United Healthcare Commercial	$13.68

cevimeline 30 mg Cap [VDMC]

Facility

$4.33

Service Code	HCPCS A9270
Hospital Charge Code	10377098
Hospital Revenue Code	259
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna of IA Commercial	$3.90
Rate for Payer: Aetna of IA Medical Rental Products	$3.90
Rate for Payer: Cash Price	$3.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.25
Rate for Payer: Medical Associates Commercial	$3.25
Rate for Payer: Midlands Choice Commercial	$3.03
Rate for Payer: United Healthcare Commercial	$3.90

cevimeline 30 mg Cap [VDMC]

Facility

$4.33

Service Code	HCPCS A9270
Hospital Charge Code	10377098
Hospital Revenue Code	259
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna of IA Commercial	$3.90
Rate for Payer: Aetna of IA Medical Rental Products	$3.90
Rate for Payer: Aetna of IA Medicare	$2.47
Rate for Payer: Amerigroup Medicaid	$2.19
Rate for Payer: Amerigroup Medicare	$2.19
Rate for Payer: Cash Price	$3.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.16
Rate for Payer: Iowa Total Care Managed Medicaid	$2.16
Rate for Payer: Medical Associates Commercial	$3.25
Rate for Payer: Medical Associates Managed Medicare	$2.16
Rate for Payer: Midlands Choice Commercial	$3.03
Rate for Payer: Molina Healthcare Managed Medicaid	$2.20
Rate for Payer: Molina Healthcare Managed Medicare	$2.20
Rate for Payer: Oscar Health of IA Commercial	$3.25
Rate for Payer: Partners Health Alliance Commercial	$3.25
Rate for Payer: United Healthcare Commercial	$3.90
Rate for Payer: United Healthcare Managed Medicare	$2.55

CHANGE GASTROSTOMY TUBE

Professional

Both

$1,621.00

Service Code	CPT 43760
Hospital Charge Code	7822793
Hospital Revenue Code	981
Min. Negotiated Rate	$1,134.70
Max. Negotiated Rate	$1,215.75
Rate for Payer: Cash Price	$1,296.80
Rate for Payer: Medical Associates Commercial	$1,215.75
Rate for Payer: Midlands Choice Commercial	$1,134.70

CHANGE OF BLADDER TUBE

Professional

Both

$302.00

Service Code	CPT 51705
Hospital Charge Code	7822797
Hospital Revenue Code	981
Min. Negotiated Rate	$46.96
Max. Negotiated Rate	$211.40
Rate for Payer: Aetna of IA Medicare	$46.96
Rate for Payer: Amerigroup Medicaid	$48.56
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.35
Rate for Payer: Iowa Total Care Managed Medicaid	$47.90
Rate for Payer: Medical Associates Commercial	$84.53
Rate for Payer: Medical Associates Managed Medicare	$46.96
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: Oscar Health of IA Commercial	$81.24
Rate for Payer: Partners Health Alliance Commercial	$70.44

CHEMO ANTI-NEOPL SQ/IM

Facility

$147.00

Service Code	CPT 96401
Hospital Charge Code	8398093
Hospital Revenue Code	260
Min. Negotiated Rate	$73.47
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Aetna of IA Medicare	$83.79
Rate for Payer: Amerigroup Medicaid	$74.19
Rate for Payer: Amerigroup Medicare	$74.24
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$73.50
Rate for Payer: Iowa Total Care Managed Medicaid	$73.47
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Medical Associates Managed Medicare	$73.50
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: Molina Healthcare Managed Medicaid	$74.60
Rate for Payer: Molina Healthcare Managed Medicare	$74.56
Rate for Payer: Oscar Health of IA Commercial	$110.25
Rate for Payer: Partners Health Alliance Commercial	$110.25
Rate for Payer: United Healthcare Commercial	$132.30
Rate for Payer: United Healthcare Managed Medicare	$86.73

CHEMO ANTI-NEOPL SQ/IM

Facility

$147.00

Service Code	CPT 96401
Hospital Charge Code	8398093
Hospital Revenue Code	260
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: United Healthcare Commercial	$132.30

CHEMO CNS INTRATHECAL W LP

Facility

$435.00

Service Code	CPT 96450
Hospital Charge Code	8398092
Hospital Revenue Code	260
Min. Negotiated Rate	$304.50
Max. Negotiated Rate	$391.50
Rate for Payer: Aetna of IA Commercial	$391.50
Rate for Payer: Aetna of IA Medical Rental Products	$391.50
Rate for Payer: Cash Price	$348.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$326.25
Rate for Payer: Medical Associates Commercial	$326.25
Rate for Payer: Midlands Choice Commercial	$304.50
Rate for Payer: United Healthcare Commercial	$391.50

CHEMO CNS INTRATHECAL W LP

Facility

$435.00

Service Code	CPT 96450
Hospital Charge Code	8398092
Hospital Revenue Code	260
Min. Negotiated Rate	$217.41
Max. Negotiated Rate	$609.03
Rate for Payer: Aetna of IA Commercial	$391.50
Rate for Payer: Aetna of IA Medical Rental Products	$391.50
Rate for Payer: Aetna of IA Medicare	$247.95
Rate for Payer: Amerigroup Medicaid	$219.54
Rate for Payer: Amerigroup Medicare	$219.68
Rate for Payer: Cash Price	$348.00
Rate for Payer: Cash Price	$348.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$326.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$217.50
Rate for Payer: Iowa Total Care Managed Medicaid	$217.41
Rate for Payer: Medical Associates Commercial	$326.25
Rate for Payer: Medical Associates Managed Medicare	$217.50
Rate for Payer: Midlands Choice Commercial	$304.50
Rate for Payer: Molina Healthcare Managed Medicaid	$220.76
Rate for Payer: Molina Healthcare Managed Medicare	$220.63
Rate for Payer: Oscar Health of IA Commercial	$326.25
Rate for Payer: Partners Health Alliance Commercial	$326.25
Rate for Payer: United Healthcare Commercial	$391.50
Rate for Payer: United Healthcare Managed Medicare	$256.65
Rate for Payer: Wellmark IA HMO	$553.66
Rate for Payer: Wellmark IA PPO	$609.03

CHEMO INFUSION

Facility

$579.00

Service Code	CPT 96413
Hospital Charge Code	8378850
Hospital Revenue Code	260
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: United Healthcare Commercial	$521.10

CHEMO INFUSION

Facility

$579.00

Service Code	CPT 96413
Hospital Charge Code	8378850
Hospital Revenue Code	260
Min. Negotiated Rate	$289.38
Max. Negotiated Rate	$610.39
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Aetna of IA Medicare	$330.03
Rate for Payer: Amerigroup Medicaid	$292.22
Rate for Payer: Amerigroup Medicare	$292.40
Rate for Payer: Cash Price	$463.20
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$289.50
Rate for Payer: Iowa Total Care Managed Medicaid	$289.38
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Medical Associates Managed Medicare	$289.50
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: Molina Healthcare Managed Medicaid	$293.84
Rate for Payer: Molina Healthcare Managed Medicare	$293.67
Rate for Payer: Oscar Health of IA Commercial	$434.25
Rate for Payer: Partners Health Alliance Commercial	$434.25
Rate for Payer: United Healthcare Commercial	$521.10
Rate for Payer: United Healthcare Managed Medicare	$341.61
Rate for Payer: Wellmark IA HMO	$554.90
Rate for Payer: Wellmark IA PPO	$610.39

Know your out-of-pocket cost for care.

All Charges