Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$333.49
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$302.74
Rate for Payer: Wellmark IA PPO	$333.49

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	$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 ANTI-NEOPL SQ/IM

Facility

$147.00

Service Code	CPT 96401
Hospital Charge Code	8398093
Hospital Revenue Code	260
Min. Negotiated Rate	$37.58
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

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	$690.40
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$626.76
Rate for Payer: Wellmark IA PPO	$690.40

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	$4,161.95
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$3,778.26
Rate for Payer: Wellmark IA PPO	$4,161.95

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	$598.25
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

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	$690.40
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$626.76
Rate for Payer: Wellmark IA PPO	$690.40

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	$37.58
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

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 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 IVF EA ADD'L SEQ INF

Facility

$347.00

Service Code	CPT 96417
Hospital Charge Code	8378853
Hospital Revenue Code	260
Min. Negotiated Rate	$156.15
Max. Negotiated Rate	$598.25
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

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	$37.58
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC

Facility

$34,621.54

Service Code	MSDRG 837
Min. Negotiated Rate	$34,119.76
Max. Negotiated Rate	$34,621.54
Rate for Payer: Amerigroup Medicaid	$34,454.27
Rate for Payer: Iowa Total Care Managed Medicaid	$34,119.76
Rate for Payer: Molina Healthcare Managed Medicaid	$34,621.54

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT

Facility

$13,734.67

Service Code	MSDRG 838
Min. Negotiated Rate	$13,535.61
Max. Negotiated Rate	$13,734.67
Rate for Payer: Amerigroup Medicaid	$13,668.31
Rate for Payer: Iowa Total Care Managed Medicaid	$13,535.61
Rate for Payer: Molina Healthcare Managed Medicaid	$13,734.67

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$10,523.38

Service Code	MSDRG 839
Min. Negotiated Rate	$10,370.86
Max. Negotiated Rate	$10,523.38
Rate for Payer: Amerigroup Medicaid	$10,472.54
Rate for Payer: Iowa Total Care Managed Medicaid	$10,370.86
Rate for Payer: Molina Healthcare Managed Medicaid	$10,523.38

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC

Facility

$12,389.12

Service Code	MSDRG 847
Min. Negotiated Rate	$12,209.57
Max. Negotiated Rate	$12,389.12
Rate for Payer: Amerigroup Medicaid	$12,329.27
Rate for Payer: Iowa Total Care Managed Medicaid	$12,209.57
Rate for Payer: Molina Healthcare Managed Medicaid	$12,389.12

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC

Facility

$12,534.38

Service Code	MSDRG 846
Min. Negotiated Rate	$12,352.71
Max. Negotiated Rate	$12,534.38
Rate for Payer: Amerigroup Medicaid	$12,473.82
Rate for Payer: Iowa Total Care Managed Medicaid	$12,352.71
Rate for Payer: Molina Healthcare Managed Medicaid	$12,534.38

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$10,300.44

Service Code	MSDRG 848
Min. Negotiated Rate	$10,151.15
Max. Negotiated Rate	$10,300.44
Rate for Payer: Amerigroup Medicaid	$10,250.67
Rate for Payer: Iowa Total Care Managed Medicaid	$10,151.15
Rate for Payer: Molina Healthcare Managed Medicaid	$10,300.44

CHEST PAIN

Facility

$5,755.99

Service Code	MSDRG 313
Min. Negotiated Rate	$5,672.57
Max. Negotiated Rate	$5,755.99
Rate for Payer: Amerigroup Medicaid	$5,728.19
Rate for Payer: Iowa Total Care Managed Medicaid	$5,672.57
Rate for Payer: Molina Healthcare Managed Medicaid	$5,755.99

Know your out-of-pocket cost for care.

All Charges