Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$4,029.18

Service Code	CPT 22903
Hospital Revenue Code	490
Min. Negotiated Rate	$3,657.73
Max. Negotiated Rate	$4,029.18
Rate for Payer: Wellmark IA HMO WHPI	$3,657.73
Rate for Payer: Wellmark IA PPO	$4,029.18

EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$4,029.18

Service Code	CPT 22903
Hospital Revenue Code	360
Min. Negotiated Rate	$3,657.73
Max. Negotiated Rate	$4,029.18
Rate for Payer: Wellmark IA HMO WHPI	$3,657.73
Rate for Payer: Wellmark IA PPO	$4,029.18

EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$7,382.01

Service Code	CPT 27632
Hospital Revenue Code	490
Min. Negotiated Rate	$6,701.47
Max. Negotiated Rate	$7,382.01
Rate for Payer: Wellmark IA HMO WHPI	$6,701.47
Rate for Payer: Wellmark IA PPO	$7,382.01

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

EXC MAL LESION TRUNK ARMS LEGS 3.1-4.0 CM

Professional

Both

$1,529.00

Service Code	CPT 11604
Hospital Charge Code	8825542
Hospital Revenue Code	975
Min. Negotiated Rate	$191.67
Max. Negotiated Rate	$1,146.75
Rate for Payer: Amerigroup Medicaid	$193.55
Rate for Payer: Cash Price	$1,223.20
Rate for Payer: Cash Price	$1,223.20
Rate for Payer: Iowa Total Care Managed Medicaid	$191.67
Rate for Payer: Medical Associates Commercial	$1,146.75
Rate for Payer: Midlands Choice Commercial	$1,070.30
Rate for Payer: Molina Healthcare Managed Medicaid	$192.61
Rate for Payer: Partners Health Alliance Commercial	$1,146.75
Rate for Payer: United Healthcare Commercial	$473.28
Rate for Payer: Wellmark IA HMO WHPI	$568.20
Rate for Payer: Wellmark IA PPO	$668.50

EXC S/N/H/F/G MAL+MRG 0.6-1

Facility

$652.00

Service Code	CPT 11621
Hospital Charge Code	7982964
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

EXC S/N/H/F/G MAL+MRG 0.6-1

Facility

$652.00

Service Code	CPT 11621
Hospital Charge Code	7982964
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 S/N/H/F/G MAL+MRG 1.1-2

Facility

$652.00

Service Code	CPT 11622
Hospital Charge Code	7982963
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 S/N/H/F/G MAL+MRG 1.1-2

Facility

$652.00

Service Code	CPT 11622
Hospital Charge Code	7982963
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

EXC S/N/H/F/G MAL+MRG 2.1-3

Facility

$815.00

Service Code	CPT 11623
Hospital Charge Code	7982962
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 S/N/H/F/G MAL+MRG 2.1-3

Facility

$815.00

Service Code	CPT 11623
Hospital Charge Code	7982962
Hospital Revenue Code	450
Min. Negotiated Rate	$366.75
Max. Negotiated Rate	$2,975.61
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$2,701.29
Rate for Payer: Wellmark IA PPO	$2,975.61

EXC S/N/H/F/G MAL+MRG 3.1-4

Facility

$815.00

Service Code	CPT 11624
Hospital Charge Code	7982961
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 S/N/H/F/G MAL+MRG 3.1-4

Facility

$815.00

Service Code	CPT 11624
Hospital Charge Code	7982961
Hospital Revenue Code	450
Min. Negotiated Rate	$366.75
Max. Negotiated Rate	$2,975.61
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$2,701.29
Rate for Payer: Wellmark IA PPO	$2,975.61

EXC S/N/H/F/G MAL+MRG >4 CM

Facility

$2,120.00

Service Code	CPT 11626
Hospital Charge Code	7982960
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 S/N/H/F/G MAL+MRG >4 CM

Facility

$2,120.00

Service Code	CPT 11626
Hospital Charge Code	7982960
Hospital Revenue Code	450
Min. Negotiated Rate	$954.00
Max. Negotiated Rate	$5,511.52
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$5,003.41
Rate for Payer: Wellmark IA PPO	$5,511.52

EXC TR-EXT B9+MARG 0.5 CM<

Facility

$652.00

Service Code	CPT 11400
Hospital Charge Code	7982984
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

EXC TR-EXT B9+MARG 0.5 CM<

Facility

$652.00

Service Code	CPT 11400
Hospital Charge Code	7982984
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 TR-EXT B9+MARG 0.6-1 CM

Facility

$652.00

Service Code	CPT 11401
Hospital Charge Code	7982983
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

EXC TR-EXT B9+MARG 0.6-1 CM

Facility

$652.00

Service Code	CPT 11401
Hospital Charge Code	7982983
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 TR-EXT B9+MARG 0.6-1 CM

Professional

Both

$493.00

Service Code	CPT 11401
Hospital Charge Code	7982851
Hospital Revenue Code	981
Min. Negotiated Rate	$100.75
Max. Negotiated Rate	$369.75
Rate for Payer: Amerigroup Medicaid	$101.73
Rate for Payer: Cash Price	$394.40
Rate for Payer: Cash Price	$394.40
Rate for Payer: Iowa Total Care Managed Medicaid	$100.75
Rate for Payer: Medical Associates Commercial	$369.75
Rate for Payer: Midlands Choice Commercial	$345.10
Rate for Payer: Molina Healthcare Managed Medicaid	$101.24
Rate for Payer: Partners Health Alliance Commercial	$369.75
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

EXC TR-EXT B9+MARG 1.1-2 CM

Facility

$652.00

Service Code	CPT 11402
Hospital Charge Code	4862819
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

EXC TR-EXT B9+MARG 1.1-2 CM

Facility

$652.00

Service Code	CPT 11402
Hospital Charge Code	4862819
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 TR-EXT B9+MARG 2.1-3CM/<

Facility

$750.00

Service Code	CPT 11403
Hospital Charge Code	7982982
Hospital Revenue Code	510
Min. Negotiated Rate	$337.50
Max. Negotiated Rate	$903.62
Rate for Payer: Aetna of IA Commercial	$675.00
Rate for Payer: Aetna of IA Medical Rental Products	$675.00
Rate for Payer: Aetna of IA Medicare	$427.50
Rate for Payer: Amerigroup Medicaid	$432.60
Rate for Payer: Amerigroup Medicare	$340.88
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$562.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$337.50
Rate for Payer: Iowa Total Care Managed Medicaid	$428.40
Rate for Payer: Medical Associates Commercial	$562.50
Rate for Payer: Medical Associates Managed Medicare	$337.50
Rate for Payer: Midlands Choice Commercial	$525.00
Rate for Payer: Molina Healthcare Managed Medicaid	$434.70
Rate for Payer: Partners Health Alliance Commercial	$388.12
Rate for Payer: United Healthcare Commercial	$675.00
Rate for Payer: United Healthcare Managed Medicare	$442.50
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

Know your out-of-pocket cost for care.

All Charges