Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$5,511.52
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$5,003.41
Rate for Payer: Wellmark IA PPO	$5,511.52

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	$5,511.52
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$5,003.41
Rate for Payer: Wellmark IA PPO	$5,511.52

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	$5,511.52
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$5,003.41
Rate for Payer: Wellmark IA PPO	$5,511.52

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	$178.60
Max. Negotiated Rate	$554.30
Rate for Payer: Amerigroup Medicaid	$180.35
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cash Price	$509.60
Rate for Payer: Iowa Total Care Managed Medicaid	$178.60
Rate for Payer: Medical Associates Commercial	$477.75
Rate for Payer: Midlands Choice Commercial	$445.90
Rate for Payer: Molina Healthcare Managed Medicaid	$179.48
Rate for Payer: Partners Health Alliance Commercial	$477.75
Rate for Payer: United Healthcare Commercial	$336.93
Rate for Payer: Wellmark IA HMO WHPI	$471.10
Rate for Payer: Wellmark IA PPO	$554.30

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS

Facility

$2,975.61

Service Code	CPT 11420
Hospital Revenue Code	490
Min. Negotiated Rate	$2,701.29
Max. Negotiated Rate	$2,975.61
Rate for Payer: Wellmark IA HMO WHPI	$2,701.29
Rate for Payer: Wellmark IA PPO	$2,975.61

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM

Facility

$5,511.52

Service Code	CPT 11426
Hospital Revenue Code	360
Min. Negotiated Rate	$5,003.41
Max. Negotiated Rate	$5,511.52
Rate for Payer: Wellmark IA HMO WHPI	$5,003.41
Rate for Payer: Wellmark IA PPO	$5,511.52

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM

Facility

$5,511.52

Service Code	CPT 11426
Hospital Revenue Code	490
Min. Negotiated Rate	$5,003.41
Max. Negotiated Rate	$5,511.52
Rate for Payer: Wellmark IA HMO WHPI	$5,003.41
Rate for Payer: Wellmark IA PPO	$5,511.52

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM

Facility

$903.62

Service Code	CPT 11402
Hospital Revenue Code	360
Min. Negotiated Rate	$820.31
Max. Negotiated Rate	$903.62
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM

Facility

$903.62

Service Code	CPT 11621
Hospital Revenue Code	360
Min. Negotiated Rate	$820.31
Max. Negotiated Rate	$903.62
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM

Facility

$2,975.61

Service Code	CPT 11623
Hospital Revenue Code	360
Min. Negotiated Rate	$2,701.29
Max. Negotiated Rate	$2,975.61
Rate for Payer: Wellmark IA HMO WHPI	$2,701.29
Rate for Payer: Wellmark IA PPO	$2,975.61

EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY

Facility

$3,486.38

Service Code	CPT 25111
Hospital Revenue Code	490
Min. Negotiated Rate	$3,164.98
Max. Negotiated Rate	$3,486.38
Rate for Payer: Wellmark IA HMO WHPI	$3,164.98
Rate for Payer: Wellmark IA PPO	$3,486.38

EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY

Facility

$3,486.38

Service Code	CPT 25111
Hospital Revenue Code	360
Min. Negotiated Rate	$3,164.98
Max. Negotiated Rate	$3,486.38
Rate for Payer: Wellmark IA HMO WHPI	$3,164.98
Rate for Payer: Wellmark IA PPO	$3,486.38

EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS

Facility

$4,161.95

Service Code	CPT 46230
Hospital Revenue Code	360
Min. Negotiated Rate	$3,778.26
Max. Negotiated Rate	$4,161.95
Rate for Payer: Wellmark IA HMO WHPI	$3,778.26
Rate for Payer: Wellmark IA PPO	$4,161.95

EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL

Facility

$903.62

Service Code	CPT 11750
Hospital Revenue Code	360
Min. Negotiated Rate	$820.31
Max. Negotiated Rate	$903.62
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

EXCISION OF NAIL FOLD TOE

Professional

Both

$553.00

Service Code	CPT 11765
Hospital Charge Code	7982845
Hospital Revenue Code	981
Min. Negotiated Rate	$50.13
Max. Negotiated Rate	$414.75
Rate for Payer: Amerigroup Medicaid	$50.62
Rate for Payer: Cash Price	$442.40
Rate for Payer: Cash Price	$442.40
Rate for Payer: Iowa Total Care Managed Medicaid	$50.13
Rate for Payer: Medical Associates Commercial	$414.75
Rate for Payer: Midlands Choice Commercial	$387.10
Rate for Payer: Molina Healthcare Managed Medicaid	$50.38
Rate for Payer: Partners Health Alliance Commercial	$414.75
Rate for Payer: United Healthcare Commercial	$255.44
Rate for Payer: Wellmark IA HMO WHPI	$303.90
Rate for Payer: Wellmark IA PPO	$357.50

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	$487.34
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	$442.42
Rate for Payer: Wellmark IA PPO	$487.34

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 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	$3,151.34
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$2,860.82
Rate for Payer: Wellmark IA PPO	$3,151.34

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 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	$3,151.34
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$2,860.82
Rate for Payer: Wellmark IA PPO	$3,151.34

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, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; 1.5 CM OR GREATER

Facility

$3,486.38

Service Code	CPT 26111
Hospital Revenue Code	360
Min. Negotiated Rate	$3,164.98
Max. Negotiated Rate	$3,486.38
Rate for Payer: Wellmark IA HMO WHPI	$3,164.98
Rate for Payer: Wellmark IA PPO	$3,486.38

EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM

Facility

$3,486.38

Service Code	CPT 26115
Hospital Revenue Code	360
Min. Negotiated Rate	$3,164.98
Max. Negotiated Rate	$3,486.38
Rate for Payer: Wellmark IA HMO WHPI	$3,164.98
Rate for Payer: Wellmark IA PPO	$3,486.38

Know your out-of-pocket cost for care.

All Charges