Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

10060 ID ABSCESS SIMPLE

Professional

Both

$416.00

Service Code	CPT 10060
Hospital Charge Code	8799068
Hospital Revenue Code	975
Min. Negotiated Rate	$72.26
Max. Negotiated Rate	$312.00
Rate for Payer: Amerigroup Medicaid	$72.97
Rate for Payer: Cash Price	$332.80
Rate for Payer: Cash Price	$332.80
Rate for Payer: Iowa Total Care Managed Medicaid	$72.26
Rate for Payer: Medical Associates Commercial	$312.00
Rate for Payer: Midlands Choice Commercial	$291.20
Rate for Payer: Molina Healthcare Managed Medicaid	$72.61
Rate for Payer: Partners Health Alliance Commercial	$312.00
Rate for Payer: United Healthcare Commercial	$183.09
Rate for Payer: Wellmark IA HMO WHPI	$232.80
Rate for Payer: Wellmark IA PPO	$273.80

10061 ID ABSCESS COMPLEX

Professional

Both

$693.00

Service Code	CPT 10061
Hospital Charge Code	8799069
Hospital Revenue Code	975
Min. Negotiated Rate	$132.61
Max. Negotiated Rate	$519.75
Rate for Payer: Amerigroup Medicaid	$133.91
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cash Price	$554.40
Rate for Payer: Iowa Total Care Managed Medicaid	$132.61
Rate for Payer: Medical Associates Commercial	$519.75
Rate for Payer: Midlands Choice Commercial	$485.10
Rate for Payer: Molina Healthcare Managed Medicaid	$133.26
Rate for Payer: Partners Health Alliance Commercial	$519.75
Rate for Payer: United Healthcare Commercial	$316.90
Rate for Payer: Wellmark IA HMO WHPI	$393.20
Rate for Payer: Wellmark IA PPO	$462.60

10061 ID ABSCESS COMPLEX/MULTIPLE

Professional

Both

$684.00

Service Code	CPT 10061
Hospital Charge Code	8069020
Hospital Revenue Code	975
Min. Negotiated Rate	$132.61
Max. Negotiated Rate	$513.00
Rate for Payer: Amerigroup Medicaid	$133.91
Rate for Payer: Cash Price	$547.20
Rate for Payer: Cash Price	$547.20
Rate for Payer: Iowa Total Care Managed Medicaid	$132.61
Rate for Payer: Medical Associates Commercial	$513.00
Rate for Payer: Midlands Choice Commercial	$478.80
Rate for Payer: Molina Healthcare Managed Medicaid	$133.26
Rate for Payer: Partners Health Alliance Commercial	$513.00
Rate for Payer: United Healthcare Commercial	$316.90
Rate for Payer: Wellmark IA HMO WHPI	$393.20
Rate for Payer: Wellmark IA PPO	$462.60

10080 ID pilonidal cyst

Professional

Both

$295.00

Service Code	CPT 10080
Hospital Charge Code	8799070
Hospital Revenue Code	975
Min. Negotiated Rate	$84.97
Max. Negotiated Rate	$539.10
Rate for Payer: Amerigroup Medicaid	$85.80
Rate for Payer: Cash Price	$236.00
Rate for Payer: Cash Price	$236.00
Rate for Payer: Iowa Total Care Managed Medicaid	$84.97
Rate for Payer: Medical Associates Commercial	$221.25
Rate for Payer: Midlands Choice Commercial	$206.50
Rate for Payer: Molina Healthcare Managed Medicaid	$85.38
Rate for Payer: Partners Health Alliance Commercial	$221.25
Rate for Payer: United Healthcare Commercial	$314.98
Rate for Payer: Wellmark IA HMO WHPI	$458.20
Rate for Payer: Wellmark IA PPO	$539.10

10120 ID FOREIGN BODY REMOVAL

Professional

Both

$504.00

Service Code	CPT 10120
Hospital Charge Code	8799071
Hospital Revenue Code	975
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$378.00
Rate for Payer: Amerigroup Medicaid	$83.20
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cash Price	$403.20
Rate for Payer: Iowa Total Care Managed Medicaid	$82.40
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: Molina Healthcare Managed Medicaid	$82.80
Rate for Payer: Partners Health Alliance Commercial	$378.00
Rate for Payer: United Healthcare Commercial	$228.66
Rate for Payer: Wellmark IA HMO WHPI	$279.00
Rate for Payer: Wellmark IA PPO	$328.20

10121 ID SIMPLE

Professional

Both

$906.00

Service Code	CPT 10121
Hospital Charge Code	8069115
Hospital Revenue Code	975
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$679.50
Rate for Payer: Amerigroup Medicaid	$164.80
Rate for Payer: Cash Price	$724.80
Rate for Payer: Cash Price	$724.80
Rate for Payer: Iowa Total Care Managed Medicaid	$163.20
Rate for Payer: Medical Associates Commercial	$679.50
Rate for Payer: Midlands Choice Commercial	$634.20
Rate for Payer: Molina Healthcare Managed Medicaid	$164.00
Rate for Payer: Partners Health Alliance Commercial	$679.50
Rate for Payer: United Healthcare Commercial	$409.70
Rate for Payer: Wellmark IA HMO WHPI	$484.40
Rate for Payer: Wellmark IA PPO	$569.90

10140 ID HEMATOMA/SEROMA/FLUID

Professional

Both

$540.00

Service Code	CPT 10140
Hospital Charge Code	8069092
Hospital Revenue Code	975
Min. Negotiated Rate	$87.45
Max. Negotiated Rate	$405.00
Rate for Payer: Amerigroup Medicaid	$88.31
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Iowa Total Care Managed Medicaid	$87.45
Rate for Payer: Medical Associates Commercial	$405.00
Rate for Payer: Midlands Choice Commercial	$378.00
Rate for Payer: Molina Healthcare Managed Medicaid	$87.88
Rate for Payer: Partners Health Alliance Commercial	$405.00
Rate for Payer: United Healthcare Commercial	$256.35
Rate for Payer: Wellmark IA HMO WHPI	$311.20
Rate for Payer: Wellmark IA PPO	$366.10

10180 ID CPLX POST OP WOUND INFECTION

Professional

Both

$816.00

Service Code	CPT 10180
Hospital Charge Code	8068952
Hospital Revenue Code	975
Min. Negotiated Rate	$126.55
Max. Negotiated Rate	$612.00
Rate for Payer: Amerigroup Medicaid	$127.79
Rate for Payer: Cash Price	$652.80
Rate for Payer: Cash Price	$652.80
Rate for Payer: Iowa Total Care Managed Medicaid	$126.55
Rate for Payer: Medical Associates Commercial	$612.00
Rate for Payer: Midlands Choice Commercial	$571.20
Rate for Payer: Molina Healthcare Managed Medicaid	$127.17
Rate for Payer: Partners Health Alliance Commercial	$612.00
Rate for Payer: United Healthcare Commercial	$381.01
Rate for Payer: Wellmark IA HMO WHPI	$481.30
Rate for Payer: Wellmark IA PPO	$566.30

1.0CC VISCOUS

Facility

$1,980.00

Service Code	HCPCS C1713
Hospital Charge Code	8781515
Hospital Revenue Code	278
Min. Negotiated Rate	$891.00
Max. Negotiated Rate	$1,782.00
Rate for Payer: Aetna of IA Commercial	$1,782.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,782.00
Rate for Payer: Aetna of IA Medicare	$1,128.60
Rate for Payer: Amerigroup Medicaid	$1,142.06
Rate for Payer: Amerigroup Medicare	$899.91
Rate for Payer: Cash Price	$1,584.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,485.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$891.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,130.98
Rate for Payer: Medical Associates Commercial	$1,485.00
Rate for Payer: Medical Associates Managed Medicare	$891.00
Rate for Payer: Midlands Choice Commercial	$1,386.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,147.61
Rate for Payer: Partners Health Alliance Commercial	$1,024.65
Rate for Payer: United Healthcare Commercial	$1,782.00
Rate for Payer: United Healthcare Managed Medicare	$1,168.20

1.0CC VISCOUS

Facility

$1,980.00

Service Code	HCPCS C1713
Hospital Charge Code	8781515
Hospital Revenue Code	278
Min. Negotiated Rate	$1,386.00
Max. Negotiated Rate	$1,782.00
Rate for Payer: Aetna of IA Commercial	$1,782.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,782.00
Rate for Payer: Cash Price	$1,584.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,485.00
Rate for Payer: Medical Associates Commercial	$1,485.00
Rate for Payer: Midlands Choice Commercial	$1,386.00
Rate for Payer: United Healthcare Commercial	$1,782.00

11008 REMOVAL MESH ABDOMINAL WALL

Professional

Both

$930.00

Service Code	CPT 11008
Hospital Charge Code	8069116
Hospital Revenue Code	975
Min. Negotiated Rate	$274.50
Max. Negotiated Rate	$697.50
Rate for Payer: Amerigroup Medicaid	$277.19
Rate for Payer: Cash Price	$744.00
Rate for Payer: Cash Price	$744.00
Rate for Payer: Iowa Total Care Managed Medicaid	$274.50
Rate for Payer: Medical Associates Commercial	$697.50
Rate for Payer: Midlands Choice Commercial	$651.00
Rate for Payer: Molina Healthcare Managed Medicaid	$275.85
Rate for Payer: Partners Health Alliance Commercial	$697.50
Rate for Payer: United Healthcare Commercial	$412.96
Rate for Payer: Wellmark IA HMO WHPI	$491.10
Rate for Payer: Wellmark IA PPO	$577.70

11042 SUBQ TISSUE FIRST 20 SQ CM

Professional

Both

$416.00

Service Code	CPT 11042
Hospital Charge Code	8799072
Hospital Revenue Code	975
Min. Negotiated Rate	$67.76
Max. Negotiated Rate	$312.00
Rate for Payer: Amerigroup Medicaid	$68.42
Rate for Payer: Cash Price	$332.80
Rate for Payer: Cash Price	$332.80
Rate for Payer: Iowa Total Care Managed Medicaid	$67.76
Rate for Payer: Medical Associates Commercial	$312.00
Rate for Payer: Midlands Choice Commercial	$291.20
Rate for Payer: Molina Healthcare Managed Medicaid	$68.09
Rate for Payer: Partners Health Alliance Commercial	$312.00
Rate for Payer: United Healthcare Commercial	$189.06
Rate for Payer: Wellmark IA HMO WHPI	$237.00
Rate for Payer: Wellmark IA PPO	$278.80

11043 SUBQ MUSCLE FIRST 20 SQ CM

Professional

Both

$771.00

Service Code	CPT 11043
Hospital Charge Code	8799073
Hospital Revenue Code	975
Min. Negotiated Rate	$161.84
Max. Negotiated Rate	$578.25
Rate for Payer: Amerigroup Medicaid	$163.43
Rate for Payer: Cash Price	$616.80
Rate for Payer: Cash Price	$616.80
Rate for Payer: Iowa Total Care Managed Medicaid	$161.84
Rate for Payer: Medical Associates Commercial	$578.25
Rate for Payer: Midlands Choice Commercial	$539.70
Rate for Payer: Molina Healthcare Managed Medicaid	$162.64
Rate for Payer: Partners Health Alliance Commercial	$578.25
Rate for Payer: United Healthcare Commercial	$350.54
Rate for Payer: Wellmark IA HMO WHPI	$424.80
Rate for Payer: Wellmark IA PPO	$499.80

11044 SUBQ MUSCLE BONE FIRST 20 SQ CM

Professional

Both

$1,041.00

Service Code	CPT 11044
Hospital Charge Code	8799226
Hospital Revenue Code	975
Min. Negotiated Rate	$217.58
Max. Negotiated Rate	$780.75
Rate for Payer: Amerigroup Medicaid	$219.71
Rate for Payer: Cash Price	$832.80
Rate for Payer: Cash Price	$832.80
Rate for Payer: Iowa Total Care Managed Medicaid	$217.58
Rate for Payer: Medical Associates Commercial	$780.75
Rate for Payer: Midlands Choice Commercial	$728.70
Rate for Payer: Molina Healthcare Managed Medicaid	$218.64
Rate for Payer: Partners Health Alliance Commercial	$780.75
Rate for Payer: United Healthcare Commercial	$473.44
Rate for Payer: Wellmark IA HMO WHPI	$568.20
Rate for Payer: Wellmark IA PPO	$668.50

11045 SUBQ TISSUE EA ADD'L 20 SQ CM

Professional

Both

$138.00

Service Code	CPT 11045
Hospital Charge Code	8799074
Hospital Revenue Code	975
Min. Negotiated Rate	$27.85
Max. Negotiated Rate	$103.50
Rate for Payer: Amerigroup Medicaid	$28.12
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Iowa Total Care Managed Medicaid	$27.85
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: Molina Healthcare Managed Medicaid	$27.98
Rate for Payer: Partners Health Alliance Commercial	$103.50
Rate for Payer: United Healthcare Commercial	$62.50
Rate for Payer: Wellmark IA HMO WHPI	$72.90
Rate for Payer: Wellmark IA PPO	$85.80

11046 SUBQ MUSCLE EA ADD'L 20 SQ CM

Professional

Both

$246.00

Service Code	CPT 11046
Hospital Charge Code	8799075
Hospital Revenue Code	975
Min. Negotiated Rate	$48.64
Max. Negotiated Rate	$184.50
Rate for Payer: Amerigroup Medicaid	$49.12
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Iowa Total Care Managed Medicaid	$48.64
Rate for Payer: Medical Associates Commercial	$184.50
Rate for Payer: Midlands Choice Commercial	$172.20
Rate for Payer: Molina Healthcare Managed Medicaid	$48.88
Rate for Payer: Partners Health Alliance Commercial	$184.50
Rate for Payer: United Healthcare Commercial	$111.26
Rate for Payer: Wellmark IA HMO WHPI	$133.10
Rate for Payer: Wellmark IA PPO	$156.60

11055 PARING OF CORN/CALLUS

Professional

Both

$207.00

Service Code	CPT 11055
Hospital Charge Code	8799076
Hospital Revenue Code	975
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$155.25
Rate for Payer: Amerigroup Medicaid	$20.50
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Iowa Total Care Managed Medicaid	$20.30
Rate for Payer: Medical Associates Commercial	$155.25
Rate for Payer: Midlands Choice Commercial	$144.90
Rate for Payer: Molina Healthcare Managed Medicaid	$20.40
Rate for Payer: Partners Health Alliance Commercial	$155.25
Rate for Payer: United Healthcare Commercial	$94.27
Rate for Payer: Wellmark IA HMO WHPI	$130.10
Rate for Payer: Wellmark IA PPO	$153.00

11200 REMOVAL OF SKIN TAGS MULTIPLE FIBROCUTANEOUS TAGS ANY AREA UP TO 15 LESIONS

Professional

Both

$234.00

Service Code	CPT 11200
Hospital Charge Code	8799077
Hospital Revenue Code	975
Min. Negotiated Rate	$53.40
Max. Negotiated Rate	$199.50
Rate for Payer: Amerigroup Medicaid	$53.92
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cash Price	$187.20
Rate for Payer: Iowa Total Care Managed Medicaid	$53.40
Rate for Payer: Medical Associates Commercial	$175.50
Rate for Payer: Midlands Choice Commercial	$163.80
Rate for Payer: Molina Healthcare Managed Medicaid	$53.66
Rate for Payer: Partners Health Alliance Commercial	$175.50
Rate for Payer: United Healthcare Commercial	$133.87
Rate for Payer: Wellmark IA HMO WHPI	$169.60
Rate for Payer: Wellmark IA PPO	$199.50

11300 Shaving of lesion- trunk arms legs 0.5 cm or less

Professional

Both

$323.00

Service Code	CPT 11300
Hospital Charge Code	8799078
Hospital Revenue Code	975
Min. Negotiated Rate	$44.86
Max. Negotiated Rate	$242.25
Rate for Payer: Amerigroup Medicaid	$45.30
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cash Price	$258.40
Rate for Payer: Iowa Total Care Managed Medicaid	$44.86
Rate for Payer: Medical Associates Commercial	$242.25
Rate for Payer: Midlands Choice Commercial	$226.10
Rate for Payer: Molina Healthcare Managed Medicaid	$45.08
Rate for Payer: Partners Health Alliance Commercial	$242.25
Rate for Payer: United Healthcare Commercial	$150.29
Rate for Payer: Wellmark IA HMO WHPI	$183.50
Rate for Payer: Wellmark IA PPO	$215.90

11301 shave skin lesion

Professional

Both

$402.00

Service Code	CPT 11301
Hospital Charge Code	8799079
Hospital Revenue Code	975
Min. Negotiated Rate	$61.51
Max. Negotiated Rate	$301.50
Rate for Payer: Amerigroup Medicaid	$62.11
Rate for Payer: Cash Price	$321.60
Rate for Payer: Cash Price	$321.60
Rate for Payer: Iowa Total Care Managed Medicaid	$61.51
Rate for Payer: Medical Associates Commercial	$301.50
Rate for Payer: Midlands Choice Commercial	$281.40
Rate for Payer: Molina Healthcare Managed Medicaid	$61.81
Rate for Payer: Partners Health Alliance Commercial	$301.50
Rate for Payer: United Healthcare Commercial	$183.01
Rate for Payer: Wellmark IA HMO WHPI	$221.80
Rate for Payer: Wellmark IA PPO	$261.00

11400 Excision benign lesion- trunk arms legs less than 0.5 cm

Professional

Both

$418.00

Service Code	CPT 11400
Hospital Charge Code	8799081
Hospital Revenue Code	975
Min. Negotiated Rate	$82.77
Max. Negotiated Rate	$313.50
Rate for Payer: Amerigroup Medicaid	$83.58
Rate for Payer: Cash Price	$334.40
Rate for Payer: Cash Price	$334.40
Rate for Payer: Iowa Total Care Managed Medicaid	$82.77
Rate for Payer: Medical Associates Commercial	$313.50
Rate for Payer: Midlands Choice Commercial	$292.60
Rate for Payer: Molina Healthcare Managed Medicaid	$83.18
Rate for Payer: Partners Health Alliance Commercial	$313.50
Rate for Payer: United Healthcare Commercial	$188.74
Rate for Payer: Wellmark IA HMO WHPI	$235.20
Rate for Payer: Wellmark IA PPO	$276.70

11401 Excision benign lesion- trunk arms legs 0.6-1.0 cm

Professional

Both

$502.00

Service Code	CPT 11401
Hospital Charge Code	8799082
Hospital Revenue Code	975
Min. Negotiated Rate	$100.75
Max. Negotiated Rate	$376.50
Rate for Payer: Amerigroup Medicaid	$101.73
Rate for Payer: Cash Price	$401.60
Rate for Payer: Cash Price	$401.60
Rate for Payer: Iowa Total Care Managed Medicaid	$100.75
Rate for Payer: Medical Associates Commercial	$376.50
Rate for Payer: Midlands Choice Commercial	$351.40
Rate for Payer: Molina Healthcare Managed Medicaid	$101.24
Rate for Payer: Partners Health Alliance Commercial	$376.50
Rate for Payer: United Healthcare Commercial	$230.51
Rate for Payer: Wellmark IA HMO WHPI	$286.30
Rate for Payer: Wellmark IA PPO	$336.80

11402 Excision benign lesion- trunk arms legs 1.1 to 2.0 cm

Professional

Both

$555.00

Service Code	CPT 11402
Hospital Charge Code	8799083
Hospital Revenue Code	975
Min. Negotiated Rate	$116.93
Max. Negotiated Rate	$416.25
Rate for Payer: Amerigroup Medicaid	$118.08
Rate for Payer: Cash Price	$444.00
Rate for Payer: Cash Price	$444.00
Rate for Payer: Iowa Total Care Managed Medicaid	$116.93
Rate for Payer: Medical Associates Commercial	$416.25
Rate for Payer: Midlands Choice Commercial	$388.50
Rate for Payer: Molina Healthcare Managed Medicaid	$117.51
Rate for Payer: Partners Health Alliance Commercial	$416.25
Rate for Payer: United Healthcare Commercial	$255.46
Rate for Payer: Wellmark IA HMO WHPI	$315.40
Rate for Payer: Wellmark IA PPO	$371.10

11403 Excision benign lesion- trunk arms legs 2.1 to 3.0 cm

Professional

Both

$642.00

Service Code	CPT 11403
Hospital Charge Code	8799084
Hospital Revenue Code	975
Min. Negotiated Rate	$137.16
Max. Negotiated Rate	$481.50
Rate for Payer: Amerigroup Medicaid	$138.50
Rate for Payer: Cash Price	$513.60
Rate for Payer: Cash Price	$513.60
Rate for Payer: Iowa Total Care Managed Medicaid	$137.16
Rate for Payer: Medical Associates Commercial	$481.50
Rate for Payer: Midlands Choice Commercial	$449.40
Rate for Payer: Molina Healthcare Managed Medicaid	$137.83
Rate for Payer: Partners Health Alliance Commercial	$481.50
Rate for Payer: United Healthcare Commercial	$294.32
Rate for Payer: Wellmark IA HMO WHPI	$363.40
Rate for Payer: Wellmark IA PPO	$427.60

11404 Excision benign lesion incl margins 3.1-4.0cm

Professional

Both

$722.00

Service Code	CPT 11404
Hospital Charge Code	8799086
Hospital Revenue Code	975
Min. Negotiated Rate	$154.11
Max. Negotiated Rate	$541.50
Rate for Payer: Amerigroup Medicaid	$155.62
Rate for Payer: Cash Price	$577.60
Rate for Payer: Cash Price	$577.60
Rate for Payer: Iowa Total Care Managed Medicaid	$154.11
Rate for Payer: Medical Associates Commercial	$541.50
Rate for Payer: Midlands Choice Commercial	$505.40
Rate for Payer: Molina Healthcare Managed Medicaid	$154.87
Rate for Payer: Partners Health Alliance Commercial	$541.50
Rate for Payer: United Healthcare Commercial	$333.62
Rate for Payer: Wellmark IA HMO WHPI	$411.40
Rate for Payer: Wellmark IA PPO	$484.10

Know your out-of-pocket cost for care.

All Charges