Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$3.89
Rate for Payer: Aetna of IA Commercial	$3.89
Rate for Payer: Aetna of IA Medical Rental Products	$3.89
Rate for Payer: Cash Price	$3.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.24
Rate for Payer: Medical Associates Commercial	$3.24
Rate for Payer: Midlands Choice Commercial	$3.03
Rate for Payer: United Healthcare Commercial	$3.89

cevimeline 30 mg Cap [VDMC]

Facility

$4.33

Service Code	HCPCS A9270
Hospital Charge Code	10377098
Hospital Revenue Code	259
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$3.89
Rate for Payer: Aetna of IA Commercial	$3.89
Rate for Payer: Aetna of IA Medical Rental Products	$3.89
Rate for Payer: Aetna of IA Medicare	$2.47
Rate for Payer: Amerigroup Medicaid	$2.50
Rate for Payer: Amerigroup Medicare	$1.97
Rate for Payer: Cash Price	$3.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.24
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.95
Rate for Payer: Iowa Total Care Managed Medicaid	$2.47
Rate for Payer: Medical Associates Commercial	$3.24
Rate for Payer: Medical Associates Managed Medicare	$1.95
Rate for Payer: Midlands Choice Commercial	$3.03
Rate for Payer: Molina Healthcare Managed Medicaid	$2.51
Rate for Payer: Partners Health Alliance Commercial	$2.24
Rate for Payer: United Healthcare Commercial	$3.89
Rate for Payer: United Healthcare Managed Medicare	$2.55

CGM Setup Training Monitoring for at least 72 hours

Facility

$140.00

Service Code	CPT 95249
Hospital Charge Code	6591070
Hospital Revenue Code	920
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna of IA Commercial	$126.00
Rate for Payer: Aetna of IA Medical Rental Products	$126.00
Rate for Payer: Aetna of IA Medicare	$79.80
Rate for Payer: Amerigroup Medicaid	$80.75
Rate for Payer: Amerigroup Medicare	$63.63
Rate for Payer: Cash Price	$112.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$105.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$63.00
Rate for Payer: Iowa Total Care Managed Medicaid	$79.97
Rate for Payer: Medical Associates Commercial	$105.00
Rate for Payer: Medical Associates Managed Medicare	$63.00
Rate for Payer: Midlands Choice Commercial	$98.00
Rate for Payer: Molina Healthcare Managed Medicaid	$81.14
Rate for Payer: Partners Health Alliance Commercial	$72.45
Rate for Payer: United Healthcare Commercial	$126.00
Rate for Payer: United Healthcare Managed Medicare	$82.60

CGM Setup Training Monitoring for at least 72 hours

Facility

$140.00

Service Code	CPT 95249
Hospital Charge Code	6591070
Hospital Revenue Code	920
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna of IA Commercial	$126.00
Rate for Payer: Aetna of IA Medical Rental Products	$126.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$105.00
Rate for Payer: Medical Associates Commercial	$105.00
Rate for Payer: Midlands Choice Commercial	$98.00
Rate for Payer: United Healthcare Commercial	$126.00

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
Rate for Payer: Partners Health Alliance Commercial	$1,215.75

CHANGE GASTROSTOMY TUBE

Facility

$517.00

Service Code	CPT 43760
Hospital Charge Code	4864966
Hospital Revenue Code	450
Min. Negotiated Rate	$232.65
Max. Negotiated Rate	$465.30
Rate for Payer: Aetna of IA Commercial	$465.30
Rate for Payer: Aetna of IA Medical Rental Products	$465.30
Rate for Payer: Aetna of IA Medicare	$294.69
Rate for Payer: Amerigroup Medicaid	$298.21
Rate for Payer: Amerigroup Medicare	$234.98
Rate for Payer: Cash Price	$413.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$387.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$232.65
Rate for Payer: Iowa Total Care Managed Medicaid	$295.31
Rate for Payer: Medical Associates Commercial	$387.75
Rate for Payer: Medical Associates Managed Medicare	$232.65
Rate for Payer: Midlands Choice Commercial	$361.90
Rate for Payer: Molina Healthcare Managed Medicaid	$299.65
Rate for Payer: Partners Health Alliance Commercial	$267.55
Rate for Payer: United Healthcare Commercial	$465.30
Rate for Payer: United Healthcare Managed Medicare	$305.03

CHANGE GASTROSTOMY TUBE

Facility

$517.00

Service Code	CPT 43760
Hospital Charge Code	4864966
Hospital Revenue Code	450
Min. Negotiated Rate	$361.90
Max. Negotiated Rate	$465.30
Rate for Payer: Aetna of IA Commercial	$465.30
Rate for Payer: Aetna of IA Medical Rental Products	$465.30
Rate for Payer: Cash Price	$413.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$387.75
Rate for Payer: Medical Associates Commercial	$387.75
Rate for Payer: Midlands Choice Commercial	$361.90
Rate for Payer: United Healthcare Commercial	$465.30

CHANGE OF BLADDER TUBE

Professional

Both

$302.00

Service Code	CPT 51705
Hospital Charge Code	7822797
Hospital Revenue Code	981
Min. Negotiated Rate	$143.70
Max. Negotiated Rate	$226.50
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Medical Associates Commercial	$226.50
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: Partners Health Alliance Commercial	$226.50
Rate for Payer: United Healthcare Commercial	$143.70

CHANGE OF BLADDER TUBE

Facility

$397.00

Service Code	CPT 51705
Hospital Charge Code	4863329
Hospital Revenue Code	450
Min. Negotiated Rate	$178.65
Max. Negotiated Rate	$357.30
Rate for Payer: Aetna of IA Commercial	$357.30
Rate for Payer: Aetna of IA Medical Rental Products	$357.30
Rate for Payer: Aetna of IA Medicare	$226.29
Rate for Payer: Amerigroup Medicaid	$228.99
Rate for Payer: Amerigroup Medicare	$180.44
Rate for Payer: Cash Price	$317.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$297.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$178.65
Rate for Payer: Iowa Total Care Managed Medicaid	$226.77
Rate for Payer: Medical Associates Commercial	$297.75
Rate for Payer: Medical Associates Managed Medicare	$178.65
Rate for Payer: Midlands Choice Commercial	$277.90
Rate for Payer: Molina Healthcare Managed Medicaid	$230.10
Rate for Payer: Partners Health Alliance Commercial	$205.45
Rate for Payer: United Healthcare Commercial	$357.30
Rate for Payer: United Healthcare Managed Medicare	$234.23

CHANGE OF BLADDER TUBE

Facility

$397.00

Service Code	CPT 51705
Hospital Charge Code	4863329
Hospital Revenue Code	450
Min. Negotiated Rate	$277.90
Max. Negotiated Rate	$357.30
Rate for Payer: Aetna of IA Commercial	$357.30
Rate for Payer: Aetna of IA Medical Rental Products	$357.30
Rate for Payer: Cash Price	$317.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$297.75
Rate for Payer: Medical Associates Commercial	$297.75
Rate for Payer: Midlands Choice Commercial	$277.90
Rate for Payer: United Healthcare Commercial	$357.30

CHEMICAL CAUTERY TISSUE

Facility

$275.00

Service Code	CPT 17250
Hospital Charge Code	7855096
Hospital Revenue Code	450
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$247.50
Rate for Payer: Aetna of IA Commercial	$247.50
Rate for Payer: Aetna of IA Medical Rental Products	$247.50
Rate for Payer: Aetna of IA Medicare	$156.75
Rate for Payer: Amerigroup Medicaid	$158.62
Rate for Payer: Amerigroup Medicare	$124.99
Rate for Payer: Cash Price	$220.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$206.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$123.75
Rate for Payer: Iowa Total Care Managed Medicaid	$157.08
Rate for Payer: Medical Associates Commercial	$206.25
Rate for Payer: Medical Associates Managed Medicare	$123.75
Rate for Payer: Midlands Choice Commercial	$192.50
Rate for Payer: Molina Healthcare Managed Medicaid	$159.39
Rate for Payer: Partners Health Alliance Commercial	$142.31
Rate for Payer: United Healthcare Commercial	$247.50
Rate for Payer: United Healthcare Managed Medicare	$162.25

CHEMICAL CAUTERY TISSUE

Facility

$275.00

Service Code	CPT 17250
Hospital Charge Code	7855096
Hospital Revenue Code	450
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$247.50
Rate for Payer: Aetna of IA Commercial	$247.50
Rate for Payer: Aetna of IA Medical Rental Products	$247.50
Rate for Payer: Cash Price	$220.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$206.25
Rate for Payer: Medical Associates Commercial	$206.25
Rate for Payer: Midlands Choice Commercial	$192.50
Rate for Payer: United Healthcare Commercial	$247.50

CHEMO ANTI-NEOPL SQ/IM

Facility

$147.00

Service Code	CPT 96401
Hospital Charge Code	8398093
Hospital Revenue Code	260
Min. Negotiated Rate	$66.15
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	$84.79
Rate for Payer: Amerigroup Medicare	$66.81
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	$66.15
Rate for Payer: Iowa Total Care Managed Medicaid	$83.97
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Medical Associates Managed Medicare	$66.15
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: Molina Healthcare Managed Medicaid	$85.20
Rate for Payer: Partners Health Alliance Commercial	$76.07
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	$195.75
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: Aetna of IA Medicare	$247.95
Rate for Payer: Amerigroup Medicaid	$250.91
Rate for Payer: Amerigroup Medicare	$197.71
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	$195.75
Rate for Payer: Iowa Total Care Managed Medicaid	$248.47
Rate for Payer: Medical Associates Commercial	$326.25
Rate for Payer: Medical Associates Managed Medicare	$195.75
Rate for Payer: Midlands Choice Commercial	$304.50
Rate for Payer: Molina Healthcare Managed Medicaid	$252.13
Rate for Payer: Partners Health Alliance Commercial	$225.11
Rate for Payer: United Healthcare Commercial	$391.50
Rate for Payer: United Healthcare Managed Medicare	$256.65

CHEMODENERVATION ANAL MUSC

Facility

$1,894.00

Service Code	CPT 46505
Hospital Charge Code	7983037
Hospital Revenue Code	450
Min. Negotiated Rate	$852.30
Max. Negotiated Rate	$1,704.60
Rate for Payer: Aetna of IA Commercial	$1,704.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,704.60
Rate for Payer: Aetna of IA Medicare	$1,079.58
Rate for Payer: Amerigroup Medicaid	$1,092.46
Rate for Payer: Amerigroup Medicare	$860.82
Rate for Payer: Cash Price	$1,515.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,420.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$852.30
Rate for Payer: Iowa Total Care Managed Medicaid	$1,081.85
Rate for Payer: Medical Associates Commercial	$1,420.50
Rate for Payer: Medical Associates Managed Medicare	$852.30
Rate for Payer: Midlands Choice Commercial	$1,325.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,097.76
Rate for Payer: Partners Health Alliance Commercial	$980.14
Rate for Payer: United Healthcare Commercial	$1,704.60
Rate for Payer: United Healthcare Managed Medicare	$1,117.46

CHEMODENERVATION ANAL MUSC

Facility

$1,894.00

Service Code	CPT 46505
Hospital Charge Code	7983037
Hospital Revenue Code	450
Min. Negotiated Rate	$1,325.80
Max. Negotiated Rate	$1,704.60
Rate for Payer: Aetna of IA Commercial	$1,704.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,704.60
Rate for Payer: Cash Price	$1,515.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,420.50
Rate for Payer: Medical Associates Commercial	$1,420.50
Rate for Payer: Midlands Choice Commercial	$1,325.80
Rate for Payer: United Healthcare Commercial	$1,704.60

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	$260.55
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	$333.97
Rate for Payer: Amerigroup Medicare	$263.16
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	$260.55
Rate for Payer: Iowa Total Care Managed Medicaid	$330.72
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Medical Associates Managed Medicare	$260.55
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: Molina Healthcare Managed Medicaid	$335.59
Rate for Payer: Partners Health Alliance Commercial	$299.63
Rate for Payer: United Healthcare Commercial	$521.10
Rate for Payer: United Healthcare Managed Medicare	$341.61

CHEMO IV EA ADD'L HR

Facility

$435.00

Service Code	CPT 96415
Hospital Charge Code	8378852
Hospital Revenue Code	260
Min. Negotiated Rate	$195.75
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: Aetna of IA Medicare	$247.95
Rate for Payer: Amerigroup Medicaid	$250.91
Rate for Payer: Amerigroup Medicare	$197.71
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	$195.75
Rate for Payer: Iowa Total Care Managed Medicaid	$248.47
Rate for Payer: Medical Associates Commercial	$326.25
Rate for Payer: Medical Associates Managed Medicare	$195.75
Rate for Payer: Midlands Choice Commercial	$304.50
Rate for Payer: Molina Healthcare Managed Medicaid	$252.13
Rate for Payer: Partners Health Alliance Commercial	$225.11
Rate for Payer: United Healthcare Commercial	$391.50
Rate for Payer: United Healthcare Managed Medicare	$256.65

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	$156.15
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	$200.15
Rate for Payer: Amerigroup Medicare	$157.71
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	$156.15
Rate for Payer: Iowa Total Care Managed Medicaid	$198.21
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Medical Associates Managed Medicare	$156.15
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: Molina Healthcare Managed Medicaid	$201.12
Rate for Payer: Partners Health Alliance Commercial	$179.57
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	$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

Know your out-of-pocket cost for care.

All Charges