Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

CHEMO IV EA ADD'L HR

Facility

$435.00

Service Code	CPT 96415
Hospital Charge Code	8378852
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 IV EA ADD'L HR

Facility

$435.00

Service Code	CPT 96415
Hospital Charge Code	8378852
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 IVF EA ADD'L SEQ

Facility

$347.00

Service Code	CPT 96411
Hospital Charge Code	8378854
Hospital Revenue Code	260
Min. Negotiated Rate	$242.90
Max. Negotiated Rate	$312.30
Rate for Payer: Aetna of IA Commercial	$312.30
Rate for Payer: Aetna of IA Medical Rental Products	$312.30
Rate for Payer: Cash Price	$277.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.25
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: United Healthcare Commercial	$312.30

CHEMO IVF EA ADD'L SEQ

Facility

$347.00

Service Code	CPT 96411
Hospital Charge Code	8378854
Hospital Revenue Code	260
Min. Negotiated Rate	$173.43
Max. Negotiated Rate	$312.30
Rate for Payer: Aetna of IA Commercial	$312.30
Rate for Payer: Aetna of IA Medical Rental Products	$312.30
Rate for Payer: Aetna of IA Medicare	$197.79
Rate for Payer: Amerigroup Medicaid	$175.13
Rate for Payer: Amerigroup Medicare	$175.24
Rate for Payer: Cash Price	$277.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$173.50
Rate for Payer: Iowa Total Care Managed Medicaid	$173.43
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Medical Associates Managed Medicare	$173.50
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: Molina Healthcare Managed Medicaid	$176.10
Rate for Payer: Molina Healthcare Managed Medicare	$176.00
Rate for Payer: Oscar Health of IA Commercial	$260.25
Rate for Payer: Partners Health Alliance Commercial	$260.25
Rate for Payer: United Healthcare Commercial	$312.30
Rate for Payer: United Healthcare Managed Medicare	$204.73

CHEMO IVF EA ADD'L SEQ INF

Facility

$347.00

Service Code	CPT 96417
Hospital Charge Code	8378853
Hospital Revenue Code	260
Min. Negotiated Rate	$173.43
Max. Negotiated Rate	$610.39
Rate for Payer: Aetna of IA Commercial	$312.30
Rate for Payer: Aetna of IA Medical Rental Products	$312.30
Rate for Payer: Aetna of IA Medicare	$197.79
Rate for Payer: Amerigroup Medicaid	$175.13
Rate for Payer: Amerigroup Medicare	$175.24
Rate for Payer: Cash Price	$277.60
Rate for Payer: Cash Price	$277.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$173.50
Rate for Payer: Iowa Total Care Managed Medicaid	$173.43
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Medical Associates Managed Medicare	$173.50
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: Molina Healthcare Managed Medicaid	$176.10
Rate for Payer: Molina Healthcare Managed Medicare	$176.00
Rate for Payer: Oscar Health of IA Commercial	$260.25
Rate for Payer: Partners Health Alliance Commercial	$260.25
Rate for Payer: United Healthcare Commercial	$312.30
Rate for Payer: United Healthcare Managed Medicare	$204.73
Rate for Payer: Wellmark IA HMO	$554.90
Rate for Payer: Wellmark IA PPO	$610.39

CHEMO IVF EA ADD'L SEQ INF

Facility

$347.00

Service Code	CPT 96417
Hospital Charge Code	8378853
Hospital Revenue Code	260
Min. Negotiated Rate	$242.90
Max. Negotiated Rate	$312.30
Rate for Payer: Aetna of IA Commercial	$312.30
Rate for Payer: Aetna of IA Medical Rental Products	$312.30
Rate for Payer: Cash Price	$277.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.25
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: United Healthcare Commercial	$312.30

CHEMO IVP

Facility

$579.00

Service Code	CPT 96409
Hospital Charge Code	8378851
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 IVP

Facility

$579.00

Service Code	CPT 96409
Hospital Charge Code	8378851
Hospital Revenue Code	260
Min. Negotiated Rate	$289.38
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: 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: 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

Chemotherapy With Acute Leukemia as Secondary Diagnosis or With High Dose Chemotherapy Agent With MCC

Facility

$30,263.46

Service Code	MS-DRG 837
Hospital Charge Code	579
Min. Negotiated Rate	$29,824.86
Max. Negotiated Rate	$30,263.46
Rate for Payer: Amerigroup Medicaid	$30,117.26
Rate for Payer: Iowa Total Care Managed Medicaid	$29,824.86
Rate for Payer: Molina Healthcare Managed Medicaid	$30,263.46

Chemotherapy With Acute Leukemia as Secondary Diagnosis With CC or High Dose Chemotherapy Agent

Facility

$12,005.78

Service Code	MS-DRG 838
Hospital Charge Code	580
Min. Negotiated Rate	$11,831.79
Max. Negotiated Rate	$12,005.78
Rate for Payer: Amerigroup Medicaid	$11,947.78
Rate for Payer: Iowa Total Care Managed Medicaid	$11,831.79
Rate for Payer: Molina Healthcare Managed Medicaid	$12,005.78

Chemotherapy With Acute Leukemia as Secondary Diagnosis Without CC/MCC

Facility

$9,198.72

Service Code	MS-DRG 839
Hospital Charge Code	581
Min. Negotiated Rate	$9,065.40
Max. Negotiated Rate	$9,198.72
Rate for Payer: Amerigroup Medicaid	$9,154.28
Rate for Payer: Iowa Total Care Managed Medicaid	$9,065.40
Rate for Payer: Molina Healthcare Managed Medicaid	$9,198.72

Chemotherapy Without Acute Leukemia as Secondary Diagnosis With CC

Facility

$10,829.61

Service Code	MS-DRG 847
Hospital Charge Code	589
Min. Negotiated Rate	$10,672.66
Max. Negotiated Rate	$10,829.61
Rate for Payer: Amerigroup Medicaid	$10,777.29
Rate for Payer: Iowa Total Care Managed Medicaid	$10,672.66
Rate for Payer: Molina Healthcare Managed Medicaid	$10,829.61

Chemotherapy Without Acute Leukemia as Secondary Diagnosis With MCC

Facility

$10,956.57

Service Code	MS-DRG 846
Hospital Charge Code	588
Min. Negotiated Rate	$10,797.78
Max. Negotiated Rate	$10,956.57
Rate for Payer: Amerigroup Medicaid	$10,903.64
Rate for Payer: Iowa Total Care Managed Medicaid	$10,797.78
Rate for Payer: Molina Healthcare Managed Medicaid	$10,956.57

Chemotherapy Without Acute Leukemia as Secondary Diagnosis Without CC/MCC

Facility

$9,003.84

Service Code	MS-DRG 848
Hospital Charge Code	590
Min. Negotiated Rate	$8,873.35
Max. Negotiated Rate	$9,003.84
Rate for Payer: Amerigroup Medicaid	$8,960.34
Rate for Payer: Iowa Total Care Managed Medicaid	$8,873.35
Rate for Payer: Molina Healthcare Managed Medicaid	$9,003.84

Chest Pain

Facility

$5,031.45

Service Code	MS-DRG 313
Hospital Charge Code	170
Min. Negotiated Rate	$4,958.53
Max. Negotiated Rate	$5,031.45
Rate for Payer: Amerigroup Medicaid	$5,007.14
Rate for Payer: Iowa Total Care Managed Medicaid	$4,958.53
Rate for Payer: Molina Healthcare Managed Medicaid	$5,031.45

CHEST PHYSIOTHERAPY, SUBSQ

Facility

$109.00

Service Code	CPT 94668
Hospital Charge Code	4770828
Hospital Revenue Code	410
Min. Negotiated Rate	$54.48
Max. Negotiated Rate	$360.78
Rate for Payer: Aetna of IA Commercial	$98.10
Rate for Payer: Aetna of IA Medical Rental Products	$98.10
Rate for Payer: Aetna of IA Medicare	$62.13
Rate for Payer: Amerigroup Medicaid	$55.01
Rate for Payer: Amerigroup Medicare	$55.04
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cash Price	$87.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$54.50
Rate for Payer: Iowa Total Care Managed Medicaid	$54.48
Rate for Payer: Medical Associates Commercial	$81.75
Rate for Payer: Medical Associates Managed Medicare	$54.50
Rate for Payer: Midlands Choice Commercial	$76.30
Rate for Payer: Molina Healthcare Managed Medicaid	$55.32
Rate for Payer: Molina Healthcare Managed Medicare	$55.28
Rate for Payer: Oscar Health of IA Commercial	$81.75
Rate for Payer: Partners Health Alliance Commercial	$81.75
Rate for Payer: United Healthcare Commercial	$98.10
Rate for Payer: United Healthcare Managed Medicare	$64.31
Rate for Payer: Wellmark IA HMO	$327.98
Rate for Payer: Wellmark IA PPO	$360.78

CHEST PHYSIOTHERAPY, SUBSQ

Facility

$109.00

Service Code	CPT 94668
Hospital Charge Code	4770828
Hospital Revenue Code	410
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of IA Commercial	$98.10
Rate for Payer: Aetna of IA Medical Rental Products	$98.10
Rate for Payer: Cash Price	$87.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.75
Rate for Payer: Medical Associates Commercial	$81.75
Rate for Payer: Midlands Choice Commercial	$76.30
Rate for Payer: United Healthcare Commercial	$98.10

CHEST PHYSIOTHERPY INTIAL

Facility

$154.00

Service Code	CPT 94667
Hospital Charge Code	4770827
Hospital Revenue Code	410
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$138.60
Rate for Payer: Aetna of IA Commercial	$138.60
Rate for Payer: Aetna of IA Medical Rental Products	$138.60
Rate for Payer: Cash Price	$123.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$115.50
Rate for Payer: Medical Associates Commercial	$115.50
Rate for Payer: Midlands Choice Commercial	$107.80
Rate for Payer: United Healthcare Commercial	$138.60

CHEST PHYSIOTHERPY INTIAL

Facility

$154.00

Service Code	CPT 94667
Hospital Charge Code	4770827
Hospital Revenue Code	410
Min. Negotiated Rate	$76.97
Max. Negotiated Rate	$360.78
Rate for Payer: Aetna of IA Commercial	$138.60
Rate for Payer: Aetna of IA Medical Rental Products	$138.60
Rate for Payer: Aetna of IA Medicare	$87.78
Rate for Payer: Amerigroup Medicaid	$77.72
Rate for Payer: Amerigroup Medicare	$77.77
Rate for Payer: Cash Price	$123.20
Rate for Payer: Cash Price	$123.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$115.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$77.00
Rate for Payer: Iowa Total Care Managed Medicaid	$76.97
Rate for Payer: Medical Associates Commercial	$115.50
Rate for Payer: Medical Associates Managed Medicare	$77.00
Rate for Payer: Midlands Choice Commercial	$107.80
Rate for Payer: Molina Healthcare Managed Medicaid	$78.16
Rate for Payer: Molina Healthcare Managed Medicare	$78.11
Rate for Payer: Oscar Health of IA Commercial	$115.50
Rate for Payer: Partners Health Alliance Commercial	$115.50
Rate for Payer: United Healthcare Commercial	$138.60
Rate for Payer: United Healthcare Managed Medicare	$90.86
Rate for Payer: Wellmark IA HMO	$327.98
Rate for Payer: Wellmark IA PPO	$360.78

CHEST TUBE INSERTION ER CHARGE

Professional

Both

$595.00

Hospital Charge Code	8069016
Hospital Revenue Code	981
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$446.25
Rate for Payer: Cash Price	$476.00
Rate for Payer: Medical Associates Commercial	$446.25
Rate for Payer: Midlands Choice Commercial	$416.50

Chimeric Antigen Receptor (car) T-cell Immunotherapy

Facility

$367,502.00

Service Code	MS-DRG 018
Hospital Charge Code	707
Min. Negotiated Rate	$362,175.89
Max. Negotiated Rate	$367,502.00
Rate for Payer: Amerigroup Medicaid	$365,726.63
Rate for Payer: Iowa Total Care Managed Medicaid	$362,175.89
Rate for Payer: Molina Healthcare Managed Medicaid	$367,502.00

chlordiazePOXIDE 25 mg Cap [VDMC]

Facility

$3.52

Service Code	HCPCS A9270
Hospital Charge Code	10377368
Hospital Revenue Code	259
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$3.17
Rate for Payer: Aetna of IA Commercial	$3.17
Rate for Payer: Aetna of IA Medical Rental Products	$3.17
Rate for Payer: Cash Price	$2.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.64
Rate for Payer: Medical Associates Commercial	$2.64
Rate for Payer: Midlands Choice Commercial	$2.46
Rate for Payer: United Healthcare Commercial	$3.17

chlordiazePOXIDE 25 mg Cap [VDMC]

Facility

$3.52

Service Code	HCPCS A9270
Hospital Charge Code	10377368
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$3.17
Rate for Payer: Aetna of IA Commercial	$3.17
Rate for Payer: Aetna of IA Medical Rental Products	$3.17
Rate for Payer: Aetna of IA Medicare	$2.01
Rate for Payer: Amerigroup Medicaid	$1.78
Rate for Payer: Amerigroup Medicare	$1.78
Rate for Payer: Cash Price	$2.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.64
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.76
Rate for Payer: Iowa Total Care Managed Medicaid	$1.76
Rate for Payer: Medical Associates Commercial	$2.64
Rate for Payer: Medical Associates Managed Medicare	$1.76
Rate for Payer: Midlands Choice Commercial	$2.46
Rate for Payer: Molina Healthcare Managed Medicaid	$1.79
Rate for Payer: Molina Healthcare Managed Medicare	$1.79
Rate for Payer: Oscar Health of IA Commercial	$2.64
Rate for Payer: Partners Health Alliance Commercial	$2.64
Rate for Payer: United Healthcare Commercial	$3.17
Rate for Payer: United Healthcare Managed Medicare	$2.08

chlordiazePOXIDE 5 mg Cap [VDMC]

Facility

$3.70

Service Code	HCPCS A9270
Hospital Charge Code	10377299
Hospital Revenue Code	259
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$3.33
Rate for Payer: Aetna of IA Commercial	$3.33
Rate for Payer: Aetna of IA Medical Rental Products	$3.33
Rate for Payer: Aetna of IA Medicare	$2.11
Rate for Payer: Amerigroup Medicaid	$1.87
Rate for Payer: Amerigroup Medicare	$1.87
Rate for Payer: Cash Price	$2.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.78
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.85
Rate for Payer: Iowa Total Care Managed Medicaid	$1.85
Rate for Payer: Medical Associates Commercial	$2.78
Rate for Payer: Medical Associates Managed Medicare	$1.85
Rate for Payer: Midlands Choice Commercial	$2.59
Rate for Payer: Molina Healthcare Managed Medicaid	$1.88
Rate for Payer: Molina Healthcare Managed Medicare	$1.88
Rate for Payer: Oscar Health of IA Commercial	$2.78
Rate for Payer: Partners Health Alliance Commercial	$2.78
Rate for Payer: United Healthcare Commercial	$3.33
Rate for Payer: United Healthcare Managed Medicare	$2.18

chlordiazePOXIDE 5 mg Cap [VDMC]

Facility

$3.70

Service Code	HCPCS A9270
Hospital Charge Code	10377299
Hospital Revenue Code	259
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$3.33
Rate for Payer: Aetna of IA Commercial	$3.33
Rate for Payer: Aetna of IA Medical Rental Products	$3.33
Rate for Payer: Cash Price	$2.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.78
Rate for Payer: Medical Associates Commercial	$2.78
Rate for Payer: Midlands Choice Commercial	$2.59
Rate for Payer: United Healthcare Commercial	$3.33

Know your out-of-pocket cost for care.

All Charges