Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

EXC H-F-NK-SP B9+MARG 2.1-3

Facility

$815.00

Service Code	CPT 11423
Hospital Charge Code	7982987
Hospital Revenue Code	450
Min. Negotiated Rate	$366.75
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Aetna of IA Medicare	$464.55
Rate for Payer: Amerigroup Medicaid	$470.09
Rate for Payer: Amerigroup Medicare	$370.42
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$366.75
Rate for Payer: Iowa Total Care Managed Medicaid	$465.53
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Medical Associates Managed Medicare	$366.75
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: Molina Healthcare Managed Medicaid	$472.37
Rate for Payer: Partners Health Alliance Commercial	$421.76
Rate for Payer: United Healthcare Commercial	$733.50
Rate for Payer: United Healthcare Managed Medicare	$480.85

EXC H-F-NK-SP B9+MARG 2.1-3

Facility

$815.00

Service Code	CPT 11423
Hospital Charge Code	7982987
Hospital Revenue Code	450
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: United Healthcare Commercial	$733.50

EXC H-F-NK-SP B9+MARG 3.1-4

Facility

$2,120.00

Service Code	CPT 11424
Hospital Charge Code	7982986
Hospital Revenue Code	450
Min. Negotiated Rate	$954.00
Max. Negotiated Rate	$1,908.00
Rate for Payer: Aetna of IA Commercial	$1,908.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,908.00
Rate for Payer: Aetna of IA Medicare	$1,208.40
Rate for Payer: Amerigroup Medicaid	$1,222.82
Rate for Payer: Amerigroup Medicare	$963.54
Rate for Payer: Cash Price	$1,696.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,590.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$954.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,210.94
Rate for Payer: Medical Associates Commercial	$1,590.00
Rate for Payer: Medical Associates Managed Medicare	$954.00
Rate for Payer: Midlands Choice Commercial	$1,484.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,228.75
Rate for Payer: Partners Health Alliance Commercial	$1,097.10
Rate for Payer: United Healthcare Commercial	$1,908.00
Rate for Payer: United Healthcare Managed Medicare	$1,250.80

EXC H-F-NK-SP B9+MARG 3.1-4

Facility

$2,120.00

Service Code	CPT 11424
Hospital Charge Code	7982986
Hospital Revenue Code	450
Min. Negotiated Rate	$1,484.00
Max. Negotiated Rate	$1,908.00
Rate for Payer: Aetna of IA Commercial	$1,908.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,908.00
Rate for Payer: Cash Price	$1,696.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,590.00
Rate for Payer: Medical Associates Commercial	$1,590.00
Rate for Payer: Midlands Choice Commercial	$1,484.00
Rate for Payer: United Healthcare Commercial	$1,908.00

EXC H-F-NK-SP B9+MARG >4 CM

Facility

$2,120.00

Service Code	CPT 11426
Hospital Charge Code	7982985
Hospital Revenue Code	450
Min. Negotiated Rate	$954.00
Max. Negotiated Rate	$1,908.00
Rate for Payer: Aetna of IA Commercial	$1,908.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,908.00
Rate for Payer: Aetna of IA Medicare	$1,208.40
Rate for Payer: Amerigroup Medicaid	$1,222.82
Rate for Payer: Amerigroup Medicare	$963.54
Rate for Payer: Cash Price	$1,696.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,590.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$954.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,210.94
Rate for Payer: Medical Associates Commercial	$1,590.00
Rate for Payer: Medical Associates Managed Medicare	$954.00
Rate for Payer: Midlands Choice Commercial	$1,484.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,228.75
Rate for Payer: Partners Health Alliance Commercial	$1,097.10
Rate for Payer: United Healthcare Commercial	$1,908.00
Rate for Payer: United Healthcare Managed Medicare	$1,250.80

EXC H-F-NK-SP B9+MARG >4 CM

Facility

$2,120.00

Service Code	CPT 11426
Hospital Charge Code	7982985
Hospital Revenue Code	450
Min. Negotiated Rate	$1,484.00
Max. Negotiated Rate	$1,908.00
Rate for Payer: Aetna of IA Commercial	$1,908.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,908.00
Rate for Payer: Cash Price	$1,696.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,590.00
Rate for Payer: Medical Associates Commercial	$1,590.00
Rate for Payer: Midlands Choice Commercial	$1,484.00
Rate for Payer: United Healthcare Commercial	$1,908.00

EXC HIP/PELV TUM DEEP 5 CM/>

Facility

$652.00

Service Code	CPT 27045
Hospital Charge Code	7982947
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: United Healthcare Commercial	$586.80

EXC HIP/PELV TUM DEEP 5 CM/>

Facility

$652.00

Service Code	CPT 27045
Hospital Charge Code	7982947
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Aetna of IA Medicare	$371.64
Rate for Payer: Amerigroup Medicaid	$376.07
Rate for Payer: Amerigroup Medicare	$296.33
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$293.40
Rate for Payer: Iowa Total Care Managed Medicaid	$372.42
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Medical Associates Managed Medicare	$293.40
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: Molina Healthcare Managed Medicaid	$377.90
Rate for Payer: Partners Health Alliance Commercial	$337.41
Rate for Payer: United Healthcare Commercial	$586.80
Rate for Payer: United Healthcare Managed Medicare	$384.68

EXCISE EXCESSIVE SKIN THIGH

Facility

$2,743.00

Service Code	CPT 15832
Hospital Charge Code	7982975
Hospital Revenue Code	450
Min. Negotiated Rate	$1,234.35
Max. Negotiated Rate	$2,468.70
Rate for Payer: Aetna of IA Commercial	$2,468.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,468.70
Rate for Payer: Aetna of IA Medicare	$1,563.51
Rate for Payer: Amerigroup Medicaid	$1,582.16
Rate for Payer: Amerigroup Medicare	$1,246.69
Rate for Payer: Cash Price	$2,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,057.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,234.35
Rate for Payer: Iowa Total Care Managed Medicaid	$1,566.80
Rate for Payer: Medical Associates Commercial	$2,057.25
Rate for Payer: Medical Associates Managed Medicare	$1,234.35
Rate for Payer: Midlands Choice Commercial	$1,920.10
Rate for Payer: Molina Healthcare Managed Medicaid	$1,589.84
Rate for Payer: Partners Health Alliance Commercial	$1,419.50
Rate for Payer: United Healthcare Commercial	$2,468.70
Rate for Payer: United Healthcare Managed Medicare	$1,618.37

EXCISE EXCESSIVE SKIN THIGH

Facility

$2,743.00

Service Code	CPT 15832
Hospital Charge Code	7982975
Hospital Revenue Code	450
Min. Negotiated Rate	$1,920.10
Max. Negotiated Rate	$2,468.70
Rate for Payer: Aetna of IA Commercial	$2,468.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,468.70
Rate for Payer: Cash Price	$2,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,057.25
Rate for Payer: Medical Associates Commercial	$2,057.25
Rate for Payer: Midlands Choice Commercial	$1,920.10
Rate for Payer: United Healthcare Commercial	$2,468.70

EXCISE EXCESS SKIN ARM/HAND

Facility

$2,743.00

Service Code	CPT 15837
Hospital Charge Code	7982977
Hospital Revenue Code	450
Min. Negotiated Rate	$1,234.35
Max. Negotiated Rate	$2,468.70
Rate for Payer: Aetna of IA Commercial	$2,468.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,468.70
Rate for Payer: Aetna of IA Medicare	$1,563.51
Rate for Payer: Amerigroup Medicaid	$1,582.16
Rate for Payer: Amerigroup Medicare	$1,246.69
Rate for Payer: Cash Price	$2,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,057.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,234.35
Rate for Payer: Iowa Total Care Managed Medicaid	$1,566.80
Rate for Payer: Medical Associates Commercial	$2,057.25
Rate for Payer: Medical Associates Managed Medicare	$1,234.35
Rate for Payer: Midlands Choice Commercial	$1,920.10
Rate for Payer: Molina Healthcare Managed Medicaid	$1,589.84
Rate for Payer: Partners Health Alliance Commercial	$1,419.50
Rate for Payer: United Healthcare Commercial	$2,468.70
Rate for Payer: United Healthcare Managed Medicare	$1,618.37

EXCISE EXCESS SKIN ARM/HAND

Facility

$2,743.00

Service Code	CPT 15837
Hospital Charge Code	7982977
Hospital Revenue Code	450
Min. Negotiated Rate	$1,920.10
Max. Negotiated Rate	$2,468.70
Rate for Payer: Aetna of IA Commercial	$2,468.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,468.70
Rate for Payer: Cash Price	$2,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,057.25
Rate for Payer: Medical Associates Commercial	$2,057.25
Rate for Payer: Midlands Choice Commercial	$1,920.10
Rate for Payer: United Healthcare Commercial	$2,468.70

EXCISE EXCESS SKIN TISSUE

Facility

$2,743.00

Service Code	CPT 15839
Hospital Charge Code	7982976
Hospital Revenue Code	450
Min. Negotiated Rate	$1,234.35
Max. Negotiated Rate	$2,468.70
Rate for Payer: Aetna of IA Commercial	$2,468.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,468.70
Rate for Payer: Aetna of IA Medicare	$1,563.51
Rate for Payer: Amerigroup Medicaid	$1,582.16
Rate for Payer: Amerigroup Medicare	$1,246.69
Rate for Payer: Cash Price	$2,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,057.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,234.35
Rate for Payer: Iowa Total Care Managed Medicaid	$1,566.80
Rate for Payer: Medical Associates Commercial	$2,057.25
Rate for Payer: Medical Associates Managed Medicare	$1,234.35
Rate for Payer: Midlands Choice Commercial	$1,920.10
Rate for Payer: Molina Healthcare Managed Medicaid	$1,589.84
Rate for Payer: Partners Health Alliance Commercial	$1,419.50
Rate for Payer: United Healthcare Commercial	$2,468.70
Rate for Payer: United Healthcare Managed Medicare	$1,618.37

EXCISE EXCESS SKIN TISSUE

Facility

$2,743.00

Service Code	CPT 15839
Hospital Charge Code	7982976
Hospital Revenue Code	450
Min. Negotiated Rate	$1,920.10
Max. Negotiated Rate	$2,468.70
Rate for Payer: Aetna of IA Commercial	$2,468.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,468.70
Rate for Payer: Cash Price	$2,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,057.25
Rate for Payer: Medical Associates Commercial	$2,057.25
Rate for Payer: Midlands Choice Commercial	$1,920.10
Rate for Payer: United Healthcare Commercial	$2,468.70

EXCISE VAGINAL CYST OR TUMOR

Professional

Both

$637.00

Service Code	CPT 57135
Hospital Charge Code	8069120
Hospital Revenue Code	975
Min. Negotiated Rate	$336.93
Max. Negotiated Rate	$477.75
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cash Price	$509.60
Rate for Payer: Medical Associates Commercial	$477.75
Rate for Payer: Midlands Choice Commercial	$445.90
Rate for Payer: Partners Health Alliance Commercial	$477.75
Rate for Payer: United Healthcare Commercial	$336.93

EXCISION OF NAIL FOLD TOE

Professional

Both

$553.00

Service Code	CPT 11765
Hospital Charge Code	7982845
Hospital Revenue Code	981
Min. Negotiated Rate	$255.44
Max. Negotiated Rate	$414.75
Rate for Payer: Cash Price	$442.40
Rate for Payer: Cash Price	$442.40
Rate for Payer: Medical Associates Commercial	$414.75
Rate for Payer: Midlands Choice Commercial	$387.10
Rate for Payer: Partners Health Alliance Commercial	$414.75
Rate for Payer: United Healthcare Commercial	$255.44

EXCISION OF NAIL FOLD TOE

Facility

$275.00

Service Code	CPT 11765
Hospital Charge Code	4863323
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

EXCISION OF NAIL FOLD TOE

Facility

$275.00

Service Code	CPT 11765
Hospital Charge Code	4863323
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

EXCISION OF TONGUE FOLD

Facility

$1,663.00

Service Code	CPT 41115
Hospital Charge Code	7982948
Hospital Revenue Code	450
Min. Negotiated Rate	$1,164.10
Max. Negotiated Rate	$1,496.70
Rate for Payer: Aetna of IA Commercial	$1,496.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,496.70
Rate for Payer: Cash Price	$1,330.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,247.25
Rate for Payer: Medical Associates Commercial	$1,247.25
Rate for Payer: Midlands Choice Commercial	$1,164.10
Rate for Payer: United Healthcare Commercial	$1,496.70

EXCISION OF TONGUE FOLD

Facility

$1,663.00

Service Code	CPT 41115
Hospital Charge Code	7982948
Hospital Revenue Code	450
Min. Negotiated Rate	$748.35
Max. Negotiated Rate	$1,496.70
Rate for Payer: Aetna of IA Commercial	$1,496.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,496.70
Rate for Payer: Aetna of IA Medicare	$947.91
Rate for Payer: Amerigroup Medicaid	$959.22
Rate for Payer: Amerigroup Medicare	$755.83
Rate for Payer: Cash Price	$1,330.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,247.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$748.35
Rate for Payer: Iowa Total Care Managed Medicaid	$949.91
Rate for Payer: Medical Associates Commercial	$1,247.25
Rate for Payer: Medical Associates Managed Medicare	$748.35
Rate for Payer: Midlands Choice Commercial	$1,164.10
Rate for Payer: Molina Healthcare Managed Medicaid	$963.87
Rate for Payer: Partners Health Alliance Commercial	$860.60
Rate for Payer: United Healthcare Commercial	$1,496.70
Rate for Payer: United Healthcare Managed Medicare	$981.17

EXCISION OF TONGUE LESION

Facility

$1,663.00

Service Code	CPT 41110
Hospital Charge Code	7982949
Hospital Revenue Code	761
Min. Negotiated Rate	$1,164.10
Max. Negotiated Rate	$1,496.70
Rate for Payer: Aetna of IA Commercial	$1,496.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,496.70
Rate for Payer: Cash Price	$1,330.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,247.25
Rate for Payer: Medical Associates Commercial	$1,247.25
Rate for Payer: Midlands Choice Commercial	$1,164.10
Rate for Payer: United Healthcare Commercial	$1,496.70

EXCISION OF TONGUE LESION

Facility

$1,663.00

Service Code	CPT 41110
Hospital Charge Code	7982949
Hospital Revenue Code	761
Min. Negotiated Rate	$748.35
Max. Negotiated Rate	$1,496.70
Rate for Payer: Aetna of IA Commercial	$1,496.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,496.70
Rate for Payer: Aetna of IA Medicare	$947.91
Rate for Payer: Amerigroup Medicaid	$959.22
Rate for Payer: Amerigroup Medicare	$755.83
Rate for Payer: Cash Price	$1,330.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,247.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$748.35
Rate for Payer: Iowa Total Care Managed Medicaid	$949.91
Rate for Payer: Medical Associates Commercial	$1,247.25
Rate for Payer: Medical Associates Managed Medicare	$748.35
Rate for Payer: Midlands Choice Commercial	$1,164.10
Rate for Payer: Molina Healthcare Managed Medicaid	$963.87
Rate for Payer: Partners Health Alliance Commercial	$860.60
Rate for Payer: United Healthcare Commercial	$1,496.70
Rate for Payer: United Healthcare Managed Medicare	$981.17

EXC LESION 2.1-3 ER CHARGE

Professional

Both

$483.00

Hospital Charge Code	8069183
Hospital Revenue Code	981
Min. Negotiated Rate	$338.10
Max. Negotiated Rate	$362.25
Rate for Payer: Cash Price	$386.40
Rate for Payer: Medical Associates Commercial	$362.25
Rate for Payer: Midlands Choice Commercial	$338.10
Rate for Payer: Partners Health Alliance Commercial	$362.25

EXC LESION < 2 ER CHARGE

Professional

Both

$483.00

Hospital Charge Code	8069031
Hospital Revenue Code	981
Min. Negotiated Rate	$338.10
Max. Negotiated Rate	$362.25
Rate for Payer: Cash Price	$386.40
Rate for Payer: Medical Associates Commercial	$362.25
Rate for Payer: Midlands Choice Commercial	$338.10
Rate for Payer: Partners Health Alliance Commercial	$362.25

EXC LESION > 3.1 ER CHARGE

Professional

Both

$809.00

Hospital Charge Code	8069046
Hospital Revenue Code	981
Min. Negotiated Rate	$566.30
Max. Negotiated Rate	$606.75
Rate for Payer: Cash Price	$647.20
Rate for Payer: Medical Associates Commercial	$606.75
Rate for Payer: Midlands Choice Commercial	$566.30
Rate for Payer: Partners Health Alliance Commercial	$606.75

Know your out-of-pocket cost for care.

All Charges