Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

43249 ESOPH EGD DILATION <30 MM

Professional

Both

$3,362.00

Service Code	CPT 43249
Hospital Charge Code	8051990
Hospital Revenue Code	975
Min. Negotiated Rate	$982.09
Max. Negotiated Rate	$2,521.50
Rate for Payer: Amerigroup Medicaid	$991.71
Rate for Payer: Cash Price	$2,689.60
Rate for Payer: Cash Price	$2,689.60
Rate for Payer: Iowa Total Care Managed Medicaid	$982.09
Rate for Payer: Medical Associates Commercial	$2,521.50
Rate for Payer: Midlands Choice Commercial	$2,353.40
Rate for Payer: Molina Healthcare Managed Medicaid	$986.90
Rate for Payer: Partners Health Alliance Commercial	$2,521.50
Rate for Payer: United Healthcare Commercial	$1,631.89
Rate for Payer: Wellmark IA HMO WHPI	$2,053.40
Rate for Payer: Wellmark IA PPO	$2,415.80

43250 EGD W/ POLYPS REMOVAL VIA HOT FORCEPS

Professional

Both

$1,316.00

Service Code	CPT 43250
Hospital Charge Code	8069034
Hospital Revenue Code	975
Min. Negotiated Rate	$417.87
Max. Negotiated Rate	$1,014.10
Rate for Payer: Amerigroup Medicaid	$421.97
Rate for Payer: Cash Price	$1,052.80
Rate for Payer: Cash Price	$1,052.80
Rate for Payer: Iowa Total Care Managed Medicaid	$417.87
Rate for Payer: Medical Associates Commercial	$987.00
Rate for Payer: Midlands Choice Commercial	$921.20
Rate for Payer: Molina Healthcare Managed Medicaid	$419.92
Rate for Payer: Partners Health Alliance Commercial	$987.00
Rate for Payer: United Healthcare Commercial	$650.48
Rate for Payer: Wellmark IA HMO WHPI	$862.00
Rate for Payer: Wellmark IA PPO	$1,014.10

43251 EGD W/ SNARE POLYPECTOMY (HOT OR COLD SNARE)

Professional

Both

$1,458.00

Service Code	CPT 43251
Hospital Charge Code	8069171
Hospital Revenue Code	975
Min. Negotiated Rate	$460.06
Max. Negotiated Rate	$1,115.20
Rate for Payer: Amerigroup Medicaid	$464.57
Rate for Payer: Cash Price	$1,166.40
Rate for Payer: Cash Price	$1,166.40
Rate for Payer: Iowa Total Care Managed Medicaid	$460.06
Rate for Payer: Medical Associates Commercial	$1,093.50
Rate for Payer: Midlands Choice Commercial	$1,020.60
Rate for Payer: Molina Healthcare Managed Medicaid	$462.32
Rate for Payer: Partners Health Alliance Commercial	$1,093.50
Rate for Payer: United Healthcare Commercial	$718.70
Rate for Payer: Wellmark IA HMO WHPI	$947.90
Rate for Payer: Wellmark IA PPO	$1,115.20

43255 EGD with control of bleeding any method

Professional

Both

$2,189.00

Service Code	CPT 43255
Hospital Charge Code	8799174
Hospital Revenue Code	975
Min. Negotiated Rate	$396.74
Max. Negotiated Rate	$1,641.75
Rate for Payer: Amerigroup Medicaid	$400.63
Rate for Payer: Cash Price	$1,751.20
Rate for Payer: Cash Price	$1,751.20
Rate for Payer: Iowa Total Care Managed Medicaid	$396.74
Rate for Payer: Medical Associates Commercial	$1,641.75
Rate for Payer: Midlands Choice Commercial	$1,532.30
Rate for Payer: Molina Healthcare Managed Medicaid	$398.68
Rate for Payer: Partners Health Alliance Commercial	$1,641.75
Rate for Payer: United Healthcare Commercial	$987.10
Rate for Payer: Wellmark IA HMO WHPI	$1,197.20
Rate for Payer: Wellmark IA PPO	$1,408.50

43760 GASTROSTOMY CHANGE/REPOSITION

Professional

Both

$1,621.00

Service Code	CPT 43760
Hospital Charge Code	8069071
Hospital Revenue Code	975
Min. Negotiated Rate	$842.00
Max. Negotiated Rate	$1,215.75
Rate for Payer: Cash Price	$1,296.80
Rate for Payer: Cash Price	$1,296.80
Rate for Payer: Medical Associates Commercial	$1,215.75
Rate for Payer: Midlands Choice Commercial	$1,134.70
Rate for Payer: Partners Health Alliance Commercial	$1,215.75
Rate for Payer: Wellmark IA HMO WHPI	$842.00
Rate for Payer: Wellmark IA PPO	$1,028.00

43830 GASTROSTOMY PEG

Professional

Both

$2,358.00

Service Code	CPT 43830
Hospital Charge Code	8069029
Hospital Revenue Code	975
Min. Negotiated Rate	$456.65
Max. Negotiated Rate	$1,768.50
Rate for Payer: Amerigroup Medicaid	$461.13
Rate for Payer: Cash Price	$1,886.40
Rate for Payer: Cash Price	$1,886.40
Rate for Payer: Iowa Total Care Managed Medicaid	$456.65
Rate for Payer: Medical Associates Commercial	$1,768.50
Rate for Payer: Midlands Choice Commercial	$1,650.60
Rate for Payer: Molina Healthcare Managed Medicaid	$458.89
Rate for Payer: Partners Health Alliance Commercial	$1,768.50
Rate for Payer: United Healthcare Commercial	$1,057.94
Rate for Payer: Wellmark IA HMO WHPI	$1,358.10
Rate for Payer: Wellmark IA PPO	$1,597.70

44005 ENTEROLYSIS LYSIS ADHESNS OPEN

Professional

Both

$3,701.00

Service Code	CPT 44005
Hospital Charge Code	8069047
Hospital Revenue Code	975
Min. Negotiated Rate	$783.42
Max. Negotiated Rate	$2,775.75
Rate for Payer: Amerigroup Medicaid	$791.10
Rate for Payer: Cash Price	$2,960.80
Rate for Payer: Cash Price	$2,960.80
Rate for Payer: Iowa Total Care Managed Medicaid	$783.42
Rate for Payer: Medical Associates Commercial	$2,775.75
Rate for Payer: Midlands Choice Commercial	$2,590.70
Rate for Payer: Molina Healthcare Managed Medicaid	$787.26
Rate for Payer: Partners Health Alliance Commercial	$2,775.75
Rate for Payer: United Healthcare Commercial	$1,648.69
Rate for Payer: Wellmark IA HMO WHPI	$2,096.40
Rate for Payer: Wellmark IA PPO	$2,466.30

44110 Excision of 1+ lesions of small/large intestine; single enterotomy

Professional

Both

$2,862.00

Service Code	CPT 44110
Hospital Charge Code	8799175
Hospital Revenue Code	975
Min. Negotiated Rate	$605.08
Max. Negotiated Rate	$2,146.50
Rate for Payer: Amerigroup Medicaid	$611.02
Rate for Payer: Cash Price	$2,289.60
Rate for Payer: Cash Price	$2,289.60
Rate for Payer: Iowa Total Care Managed Medicaid	$605.08
Rate for Payer: Medical Associates Commercial	$2,146.50
Rate for Payer: Midlands Choice Commercial	$2,003.40
Rate for Payer: Molina Healthcare Managed Medicaid	$608.05
Rate for Payer: Partners Health Alliance Commercial	$2,146.50
Rate for Payer: United Healthcare Commercial	$1,281.42
Rate for Payer: Wellmark IA HMO WHPI	$1,636.20
Rate for Payer: Wellmark IA PPO	$1,925.00

44120 RESECT SM INTESTINE W/ANASTOMOSIS ILCOST

Professional

Both

$4,136.00

Service Code	CPT 44120
Hospital Charge Code	8069011
Hospital Revenue Code	975
Min. Negotiated Rate	$833.05
Max. Negotiated Rate	$3,102.00
Rate for Payer: Amerigroup Medicaid	$841.22
Rate for Payer: Cash Price	$3,308.80
Rate for Payer: Cash Price	$3,308.80
Rate for Payer: Iowa Total Care Managed Medicaid	$833.05
Rate for Payer: Medical Associates Commercial	$3,102.00
Rate for Payer: Midlands Choice Commercial	$2,895.20
Rate for Payer: Molina Healthcare Managed Medicaid	$837.14
Rate for Payer: Partners Health Alliance Commercial	$3,102.00
Rate for Payer: United Healthcare Commercial	$1,844.54
Rate for Payer: Wellmark IA HMO WHPI	$2,345.10
Rate for Payer: Wellmark IA PPO	$2,758.90

44139 TAKE DOWN SPLENIC FLEXURE

Professional

Both

$412.00

Service Code	CPT 44139
Hospital Charge Code	8069063
Hospital Revenue Code	975
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$309.00
Rate for Payer: Amerigroup Medicaid	$120.87
Rate for Payer: Cash Price	$329.60
Rate for Payer: Cash Price	$329.60
Rate for Payer: Iowa Total Care Managed Medicaid	$119.70
Rate for Payer: Medical Associates Commercial	$309.00
Rate for Payer: Midlands Choice Commercial	$288.40
Rate for Payer: Molina Healthcare Managed Medicaid	$120.28
Rate for Payer: Partners Health Alliance Commercial	$309.00
Rate for Payer: United Healthcare Commercial	$182.94
Rate for Payer: Wellmark IA HMO WHPI	$228.20
Rate for Payer: Wellmark IA PPO	$268.40

44140 COLECTOMY PARTIAL W/ANATOMOSIS

Professional

Both

$4,535.00

Service Code	CPT 44140
Hospital Charge Code	8068961
Hospital Revenue Code	975
Min. Negotiated Rate	$1,044.29
Max. Negotiated Rate	$3,401.25
Rate for Payer: Amerigroup Medicaid	$1,054.52
Rate for Payer: Cash Price	$3,628.00
Rate for Payer: Cash Price	$3,628.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,044.29
Rate for Payer: Medical Associates Commercial	$3,401.25
Rate for Payer: Midlands Choice Commercial	$3,174.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,049.41
Rate for Payer: Partners Health Alliance Commercial	$3,401.25
Rate for Payer: United Healthcare Commercial	$2,025.30
Rate for Payer: Wellmark IA HMO WHPI	$2,575.10
Rate for Payer: Wellmark IA PPO	$3,029.60

44143 COLECTOMY PARTAL HARTMANNS PRC

Professional

Both

$5,630.00

Service Code	CPT 44143
Hospital Charge Code	8069109
Hospital Revenue Code	975
Min. Negotiated Rate	$1,186.42
Max. Negotiated Rate	$4,222.50
Rate for Payer: Amerigroup Medicaid	$1,198.05
Rate for Payer: Cash Price	$4,504.00
Rate for Payer: Cash Price	$4,504.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,186.42
Rate for Payer: Medical Associates Commercial	$4,222.50
Rate for Payer: Midlands Choice Commercial	$3,941.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,192.24
Rate for Payer: Partners Health Alliance Commercial	$4,222.50
Rate for Payer: United Healthcare Commercial	$2,510.03
Rate for Payer: Wellmark IA HMO WHPI	$3,162.20
Rate for Payer: Wellmark IA PPO	$3,720.20

44146 LOW ANTERIOR RESECTION

Professional

Both

$7,177.00

Service Code	CPT 44146
Hospital Charge Code	8069142
Hospital Revenue Code	975
Min. Negotiated Rate	$1,420.89
Max. Negotiated Rate	$5,382.75
Rate for Payer: Amerigroup Medicaid	$1,434.82
Rate for Payer: Cash Price	$5,741.60
Rate for Payer: Cash Price	$5,741.60
Rate for Payer: Iowa Total Care Managed Medicaid	$1,420.89
Rate for Payer: Medical Associates Commercial	$5,382.75
Rate for Payer: Midlands Choice Commercial	$5,023.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,427.86
Rate for Payer: Partners Health Alliance Commercial	$5,382.75
Rate for Payer: United Healthcare Commercial	$3,196.54
Rate for Payer: Wellmark IA HMO WHPI	$4,010.10
Rate for Payer: Wellmark IA PPO	$4,717.80

44210 COLECTOMY

Professional

Both

$6,026.00

Service Code	CPT 44210
Hospital Charge Code	8069042
Hospital Revenue Code	975
Min. Negotiated Rate	$1,403.22
Max. Negotiated Rate	$4,519.50
Rate for Payer: Amerigroup Medicaid	$1,416.98
Rate for Payer: Cash Price	$4,820.80
Rate for Payer: Cash Price	$4,820.80
Rate for Payer: Iowa Total Care Managed Medicaid	$1,403.22
Rate for Payer: Medical Associates Commercial	$4,519.50
Rate for Payer: Midlands Choice Commercial	$4,218.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,410.10
Rate for Payer: Partners Health Alliance Commercial	$4,519.50
Rate for Payer: United Healthcare Commercial	$2,702.90
Rate for Payer: Wellmark IA HMO WHPI	$3,375.00
Rate for Payer: Wellmark IA PPO	$3,970.60

44310 Ileostomy or jejunostomy non-tube

Professional

Both

$3,530.00

Service Code	CPT 44310
Hospital Charge Code	8799176
Hospital Revenue Code	975
Min. Negotiated Rate	$732.23
Max. Negotiated Rate	$2,647.50
Rate for Payer: Amerigroup Medicaid	$739.41
Rate for Payer: Cash Price	$2,824.00
Rate for Payer: Cash Price	$2,824.00
Rate for Payer: Iowa Total Care Managed Medicaid	$732.23
Rate for Payer: Medical Associates Commercial	$2,647.50
Rate for Payer: Midlands Choice Commercial	$2,471.00
Rate for Payer: Molina Healthcare Managed Medicaid	$735.82
Rate for Payer: Partners Health Alliance Commercial	$2,647.50
Rate for Payer: United Healthcare Commercial	$1,577.76
Rate for Payer: Wellmark IA HMO WHPI	$1,993.20
Rate for Payer: Wellmark IA PPO	$2,344.90

44320 COLOSTOMY

Professional

Both

$4,061.00

Service Code	CPT 44320
Hospital Charge Code	8068990
Hospital Revenue Code	975
Min. Negotiated Rate	$793.49
Max. Negotiated Rate	$3,045.75
Rate for Payer: Amerigroup Medicaid	$801.27
Rate for Payer: Cash Price	$3,248.80
Rate for Payer: Cash Price	$3,248.80
Rate for Payer: Iowa Total Care Managed Medicaid	$793.49
Rate for Payer: Medical Associates Commercial	$3,045.75
Rate for Payer: Midlands Choice Commercial	$2,842.70
Rate for Payer: Molina Healthcare Managed Medicaid	$797.38
Rate for Payer: Partners Health Alliance Commercial	$3,045.75
Rate for Payer: United Healthcare Commercial	$1,814.51
Rate for Payer: Wellmark IA HMO WHPI	$2,304.00
Rate for Payer: Wellmark IA PPO	$2,710.60

44346 HERNIA REPR PARACOLOSTOMY

Professional

Both

$4,000.00

Service Code	CPT 44346
Hospital Charge Code	8069177
Hospital Revenue Code	975
Min. Negotiated Rate	$713.39
Max. Negotiated Rate	$3,000.00
Rate for Payer: Amerigroup Medicaid	$720.38
Rate for Payer: Cash Price	$3,200.00
Rate for Payer: Cash Price	$3,200.00
Rate for Payer: Iowa Total Care Managed Medicaid	$713.39
Rate for Payer: Medical Associates Commercial	$3,000.00
Rate for Payer: Midlands Choice Commercial	$2,800.00
Rate for Payer: Molina Healthcare Managed Medicaid	$716.88
Rate for Payer: Partners Health Alliance Commercial	$3,000.00
Rate for Payer: United Healthcare Commercial	$1,789.22
Rate for Payer: Wellmark IA HMO WHPI	$2,268.80
Rate for Payer: Wellmark IA PPO	$2,669.20

44602 REPAIR BOWEL OR

Professional

Both

$4,775.00

Service Code	CPT 44602
Hospital Charge Code	8069030
Hospital Revenue Code	975
Min. Negotiated Rate	$629.24
Max. Negotiated Rate	$3,581.25
Rate for Payer: Amerigroup Medicaid	$635.41
Rate for Payer: Cash Price	$3,820.00
Rate for Payer: Cash Price	$3,820.00
Rate for Payer: Iowa Total Care Managed Medicaid	$629.24
Rate for Payer: Medical Associates Commercial	$3,581.25
Rate for Payer: Midlands Choice Commercial	$3,342.50
Rate for Payer: Molina Healthcare Managed Medicaid	$632.32
Rate for Payer: Partners Health Alliance Commercial	$3,581.25
Rate for Payer: United Healthcare Commercial	$2,128.86
Rate for Payer: Wellmark IA HMO WHPI	$2,692.40
Rate for Payer: Wellmark IA PPO	$3,167.60

44604 Suture of large intestine w/o colostomy

Professional

Both

$3,577.00

Service Code	CPT 44604
Hospital Charge Code	8799177
Hospital Revenue Code	975
Min. Negotiated Rate	$794.67
Max. Negotiated Rate	$2,682.75
Rate for Payer: Amerigroup Medicaid	$802.46
Rate for Payer: Cash Price	$2,861.60
Rate for Payer: Cash Price	$2,861.60
Rate for Payer: Iowa Total Care Managed Medicaid	$794.67
Rate for Payer: Medical Associates Commercial	$2,682.75
Rate for Payer: Midlands Choice Commercial	$2,503.90
Rate for Payer: Molina Healthcare Managed Medicaid	$798.57
Rate for Payer: Partners Health Alliance Commercial	$2,682.75
Rate for Payer: United Healthcare Commercial	$1,597.46
Rate for Payer: Wellmark IA HMO WHPI	$2,020.80
Rate for Payer: Wellmark IA PPO	$2,377.40

44620 CLOSURE ENTEROSTOMY

Professional

Both

$2,935.00

Service Code	CPT 44620
Hospital Charge Code	8069130
Hospital Revenue Code	975
Min. Negotiated Rate	$609.67
Max. Negotiated Rate	$2,201.25
Rate for Payer: Amerigroup Medicaid	$615.65
Rate for Payer: Cash Price	$2,348.00
Rate for Payer: Cash Price	$2,348.00
Rate for Payer: Iowa Total Care Managed Medicaid	$609.67
Rate for Payer: Medical Associates Commercial	$2,201.25
Rate for Payer: Midlands Choice Commercial	$2,054.50
Rate for Payer: Molina Healthcare Managed Medicaid	$612.66
Rate for Payer: Partners Health Alliance Commercial	$2,201.25
Rate for Payer: United Healthcare Commercial	$1,311.25
Rate for Payer: Wellmark IA HMO WHPI	$1,657.40
Rate for Payer: Wellmark IA PPO	$1,949.80

44800 EXC MECKEL DIVERTICULUM

Professional

Both

$2,584.00

Service Code	CPT 44800
Hospital Charge Code	8069123
Hospital Revenue Code	975
Min. Negotiated Rate	$612.90
Max. Negotiated Rate	$1,938.00
Rate for Payer: Amerigroup Medicaid	$618.91
Rate for Payer: Cash Price	$2,067.20
Rate for Payer: Cash Price	$2,067.20
Rate for Payer: Iowa Total Care Managed Medicaid	$612.90
Rate for Payer: Medical Associates Commercial	$1,938.00
Rate for Payer: Midlands Choice Commercial	$1,808.80
Rate for Payer: Molina Healthcare Managed Medicaid	$615.90
Rate for Payer: Partners Health Alliance Commercial	$1,938.00
Rate for Payer: United Healthcare Commercial	$1,160.16
Rate for Payer: Wellmark IA HMO WHPI	$1,501.00
Rate for Payer: Wellmark IA PPO	$1,765.90

44950 APPENDECTOMY OPEN

Professional

Both

$2,168.00

Service Code	CPT 44950
Hospital Charge Code	8069169
Hospital Revenue Code	975
Min. Negotiated Rate	$497.38
Max. Negotiated Rate	$1,626.00
Rate for Payer: Amerigroup Medicaid	$502.26
Rate for Payer: Cash Price	$1,734.40
Rate for Payer: Cash Price	$1,734.40
Rate for Payer: Iowa Total Care Managed Medicaid	$497.38
Rate for Payer: Medical Associates Commercial	$1,626.00
Rate for Payer: Midlands Choice Commercial	$1,517.60
Rate for Payer: Molina Healthcare Managed Medicaid	$499.82
Rate for Payer: Partners Health Alliance Commercial	$1,626.00
Rate for Payer: United Healthcare Commercial	$968.70
Rate for Payer: Wellmark IA HMO WHPI	$1,238.20
Rate for Payer: Wellmark IA PPO	$1,456.70

44955 APPENDECTOMY W/OTHER PROC

Professional

Both

$285.00

Service Code	CPT 44955
Hospital Charge Code	8069018
Hospital Revenue Code	975
Min. Negotiated Rate	$97.39
Max. Negotiated Rate	$213.75
Rate for Payer: Amerigroup Medicaid	$98.34
Rate for Payer: Cash Price	$228.00
Rate for Payer: Cash Price	$228.00
Rate for Payer: Iowa Total Care Managed Medicaid	$97.39
Rate for Payer: Medical Associates Commercial	$213.75
Rate for Payer: Midlands Choice Commercial	$199.50
Rate for Payer: Molina Healthcare Managed Medicaid	$97.87
Rate for Payer: Partners Health Alliance Commercial	$213.75
Rate for Payer: United Healthcare Commercial	$126.56
Rate for Payer: Wellmark IA HMO WHPI	$158.90
Rate for Payer: Wellmark IA PPO	$187.00

44960 APPENDECTOMY OPEN RUPTURED

Professional

Both

$2,953.00

Service Code	CPT 44960
Hospital Charge Code	8069094
Hospital Revenue Code	975
Min. Negotiated Rate	$610.71
Max. Negotiated Rate	$2,214.75
Rate for Payer: Amerigroup Medicaid	$616.70
Rate for Payer: Cash Price	$2,362.40
Rate for Payer: Cash Price	$2,362.40
Rate for Payer: Iowa Total Care Managed Medicaid	$610.71
Rate for Payer: Medical Associates Commercial	$2,214.75
Rate for Payer: Midlands Choice Commercial	$2,067.10
Rate for Payer: Molina Healthcare Managed Medicaid	$613.71
Rate for Payer: Partners Health Alliance Commercial	$2,214.75
Rate for Payer: United Healthcare Commercial	$1,320.59
Rate for Payer: Wellmark IA HMO WHPI	$1,688.80
Rate for Payer: Wellmark IA PPO	$1,986.80

44970 APPENDECTOMY LAPAROSCOPIC

Professional

Both

$2,027.00

Service Code	CPT 44970
Hospital Charge Code	8069095
Hospital Revenue Code	975
Min. Negotiated Rate	$488.51
Max. Negotiated Rate	$1,520.25
Rate for Payer: Amerigroup Medicaid	$493.30
Rate for Payer: Cash Price	$1,621.60
Rate for Payer: Cash Price	$1,621.60
Rate for Payer: Iowa Total Care Managed Medicaid	$488.51
Rate for Payer: Medical Associates Commercial	$1,520.25
Rate for Payer: Midlands Choice Commercial	$1,418.90
Rate for Payer: Molina Healthcare Managed Medicaid	$490.90
Rate for Payer: Partners Health Alliance Commercial	$1,520.25
Rate for Payer: United Healthcare Commercial	$904.83
Rate for Payer: Wellmark IA HMO WHPI	$1,165.20
Rate for Payer: Wellmark IA PPO	$1,370.80

Know your out-of-pocket cost for care.

All Charges