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	$1,631.89
Max. Negotiated Rate	$2,521.50
Rate for Payer: Cash Price	$2,689.60
Rate for Payer: Cash Price	$2,689.60
Rate for Payer: Medical Associates Commercial	$2,521.50
Rate for Payer: Midlands Choice Commercial	$2,353.40
Rate for Payer: Partners Health Alliance Commercial	$2,521.50
Rate for Payer: United Healthcare Commercial	$1,631.89

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	$650.48
Max. Negotiated Rate	$987.00
Rate for Payer: Cash Price	$1,052.80
Rate for Payer: Cash Price	$1,052.80
Rate for Payer: Medical Associates Commercial	$987.00
Rate for Payer: Midlands Choice Commercial	$921.20
Rate for Payer: Partners Health Alliance Commercial	$987.00
Rate for Payer: United Healthcare Commercial	$650.48

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	$718.70
Max. Negotiated Rate	$1,093.50
Rate for Payer: Cash Price	$1,166.40
Rate for Payer: Cash Price	$1,166.40
Rate for Payer: Medical Associates Commercial	$1,093.50
Rate for Payer: Midlands Choice Commercial	$1,020.60
Rate for Payer: Partners Health Alliance Commercial	$1,093.50
Rate for Payer: United Healthcare Commercial	$718.70

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	$987.10
Max. Negotiated Rate	$1,641.75
Rate for Payer: Cash Price	$1,751.20
Rate for Payer: Cash Price	$1,751.20
Rate for Payer: Medical Associates Commercial	$1,641.75
Rate for Payer: Midlands Choice Commercial	$1,532.30
Rate for Payer: Partners Health Alliance Commercial	$1,641.75
Rate for Payer: United Healthcare Commercial	$987.10

43760 GASTROSTOMY CHANGE/REPOSITION

Professional

Both

$1,621.00

Service Code	CPT 43760
Hospital Charge Code	8069071
Hospital Revenue Code	975
Min. Negotiated Rate	$1,134.70
Max. Negotiated Rate	$1,215.75
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

43830 GASTROSTOMY PEG

Professional

Both

$2,358.00

Service Code	CPT 43830
Hospital Charge Code	8069029
Hospital Revenue Code	975
Min. Negotiated Rate	$1,057.94
Max. Negotiated Rate	$1,768.50
Rate for Payer: Cash Price	$1,886.40
Rate for Payer: Cash Price	$1,886.40
Rate for Payer: Medical Associates Commercial	$1,768.50
Rate for Payer: Midlands Choice Commercial	$1,650.60
Rate for Payer: Partners Health Alliance Commercial	$1,768.50
Rate for Payer: United Healthcare Commercial	$1,057.94

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	$1,648.69
Max. Negotiated Rate	$2,775.75
Rate for Payer: Cash Price	$2,960.80
Rate for Payer: Cash Price	$2,960.80
Rate for Payer: Medical Associates Commercial	$2,775.75
Rate for Payer: Midlands Choice Commercial	$2,590.70
Rate for Payer: Partners Health Alliance Commercial	$2,775.75
Rate for Payer: United Healthcare Commercial	$1,648.69

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	$1,281.42
Max. Negotiated Rate	$2,146.50
Rate for Payer: Cash Price	$2,289.60
Rate for Payer: Cash Price	$2,289.60
Rate for Payer: Medical Associates Commercial	$2,146.50
Rate for Payer: Midlands Choice Commercial	$2,003.40
Rate for Payer: Partners Health Alliance Commercial	$2,146.50
Rate for Payer: United Healthcare Commercial	$1,281.42

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	$1,844.54
Max. Negotiated Rate	$3,102.00
Rate for Payer: Cash Price	$3,308.80
Rate for Payer: Cash Price	$3,308.80
Rate for Payer: Medical Associates Commercial	$3,102.00
Rate for Payer: Midlands Choice Commercial	$2,895.20
Rate for Payer: Partners Health Alliance Commercial	$3,102.00
Rate for Payer: United Healthcare Commercial	$1,844.54

44139 TAKE DOWN SPLENIC FLEXURE

Professional

Both

$412.00

Service Code	CPT 44139
Hospital Charge Code	8069063
Hospital Revenue Code	975
Min. Negotiated Rate	$182.94
Max. Negotiated Rate	$309.00
Rate for Payer: Cash Price	$329.60
Rate for Payer: Cash Price	$329.60
Rate for Payer: Medical Associates Commercial	$309.00
Rate for Payer: Midlands Choice Commercial	$288.40
Rate for Payer: Partners Health Alliance Commercial	$309.00
Rate for Payer: United Healthcare Commercial	$182.94

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	$2,025.30
Max. Negotiated Rate	$3,401.25
Rate for Payer: Cash Price	$3,628.00
Rate for Payer: Cash Price	$3,628.00
Rate for Payer: Medical Associates Commercial	$3,401.25
Rate for Payer: Midlands Choice Commercial	$3,174.50
Rate for Payer: Partners Health Alliance Commercial	$3,401.25
Rate for Payer: United Healthcare Commercial	$2,025.30

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	$2,510.03
Max. Negotiated Rate	$4,222.50
Rate for Payer: Cash Price	$4,504.00
Rate for Payer: Cash Price	$4,504.00
Rate for Payer: Medical Associates Commercial	$4,222.50
Rate for Payer: Midlands Choice Commercial	$3,941.00
Rate for Payer: Partners Health Alliance Commercial	$4,222.50
Rate for Payer: United Healthcare Commercial	$2,510.03

44146 LOW ANTERIOR RESECTION

Professional

Both

$7,177.00

Service Code	CPT 44146
Hospital Charge Code	8069142
Hospital Revenue Code	975
Min. Negotiated Rate	$3,196.54
Max. Negotiated Rate	$5,382.75
Rate for Payer: Cash Price	$5,741.60
Rate for Payer: Cash Price	$5,741.60
Rate for Payer: Medical Associates Commercial	$5,382.75
Rate for Payer: Midlands Choice Commercial	$5,023.90
Rate for Payer: Partners Health Alliance Commercial	$5,382.75
Rate for Payer: United Healthcare Commercial	$3,196.54

44210 COLECTOMY

Professional

Both

$6,026.00

Service Code	CPT 44210
Hospital Charge Code	8069042
Hospital Revenue Code	975
Min. Negotiated Rate	$2,702.90
Max. Negotiated Rate	$4,519.50
Rate for Payer: Cash Price	$4,820.80
Rate for Payer: Cash Price	$4,820.80
Rate for Payer: Medical Associates Commercial	$4,519.50
Rate for Payer: Midlands Choice Commercial	$4,218.20
Rate for Payer: Partners Health Alliance Commercial	$4,519.50
Rate for Payer: United Healthcare Commercial	$2,702.90

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	$1,577.76
Max. Negotiated Rate	$2,647.50
Rate for Payer: Cash Price	$2,824.00
Rate for Payer: Cash Price	$2,824.00
Rate for Payer: Medical Associates Commercial	$2,647.50
Rate for Payer: Midlands Choice Commercial	$2,471.00
Rate for Payer: Partners Health Alliance Commercial	$2,647.50
Rate for Payer: United Healthcare Commercial	$1,577.76

44320 COLOSTOMY

Professional

Both

$4,061.00

Service Code	CPT 44320
Hospital Charge Code	8068990
Hospital Revenue Code	975
Min. Negotiated Rate	$1,814.51
Max. Negotiated Rate	$3,045.75
Rate for Payer: Cash Price	$3,248.80
Rate for Payer: Cash Price	$3,248.80
Rate for Payer: Medical Associates Commercial	$3,045.75
Rate for Payer: Midlands Choice Commercial	$2,842.70
Rate for Payer: Partners Health Alliance Commercial	$3,045.75
Rate for Payer: United Healthcare Commercial	$1,814.51

44346 HERNIA REPR PARACOLOSTOMY

Professional

Both

$4,000.00

Service Code	CPT 44346
Hospital Charge Code	8069177
Hospital Revenue Code	975
Min. Negotiated Rate	$1,789.22
Max. Negotiated Rate	$3,000.00
Rate for Payer: Cash Price	$3,200.00
Rate for Payer: Cash Price	$3,200.00
Rate for Payer: Medical Associates Commercial	$3,000.00
Rate for Payer: Midlands Choice Commercial	$2,800.00
Rate for Payer: Partners Health Alliance Commercial	$3,000.00
Rate for Payer: United Healthcare Commercial	$1,789.22

44602 REPAIR BOWEL OR

Professional

Both

$4,775.00

Service Code	CPT 44602
Hospital Charge Code	8069030
Hospital Revenue Code	975
Min. Negotiated Rate	$2,128.86
Max. Negotiated Rate	$3,581.25
Rate for Payer: Cash Price	$3,820.00
Rate for Payer: Cash Price	$3,820.00
Rate for Payer: Medical Associates Commercial	$3,581.25
Rate for Payer: Midlands Choice Commercial	$3,342.50
Rate for Payer: Partners Health Alliance Commercial	$3,581.25
Rate for Payer: United Healthcare Commercial	$2,128.86

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	$1,597.46
Max. Negotiated Rate	$2,682.75
Rate for Payer: Cash Price	$2,861.60
Rate for Payer: Cash Price	$2,861.60
Rate for Payer: Medical Associates Commercial	$2,682.75
Rate for Payer: Midlands Choice Commercial	$2,503.90
Rate for Payer: Partners Health Alliance Commercial	$2,682.75
Rate for Payer: United Healthcare Commercial	$1,597.46

44620 CLOSURE ENTEROSTOMY

Professional

Both

$2,935.00

Service Code	CPT 44620
Hospital Charge Code	8069130
Hospital Revenue Code	975
Min. Negotiated Rate	$1,311.25
Max. Negotiated Rate	$2,201.25
Rate for Payer: Cash Price	$2,348.00
Rate for Payer: Cash Price	$2,348.00
Rate for Payer: Medical Associates Commercial	$2,201.25
Rate for Payer: Midlands Choice Commercial	$2,054.50
Rate for Payer: Partners Health Alliance Commercial	$2,201.25
Rate for Payer: United Healthcare Commercial	$1,311.25

44800 EXC MECKEL DIVERTICULUM

Professional

Both

$2,584.00

Service Code	CPT 44800
Hospital Charge Code	8069123
Hospital Revenue Code	975
Min. Negotiated Rate	$1,160.16
Max. Negotiated Rate	$1,938.00
Rate for Payer: Cash Price	$2,067.20
Rate for Payer: Cash Price	$2,067.20
Rate for Payer: Medical Associates Commercial	$1,938.00
Rate for Payer: Midlands Choice Commercial	$1,808.80
Rate for Payer: Partners Health Alliance Commercial	$1,938.00
Rate for Payer: United Healthcare Commercial	$1,160.16

44950 APPENDECTOMY OPEN

Professional

Both

$2,168.00

Service Code	CPT 44950
Hospital Charge Code	8069169
Hospital Revenue Code	975
Min. Negotiated Rate	$968.70
Max. Negotiated Rate	$1,626.00
Rate for Payer: Cash Price	$1,734.40
Rate for Payer: Cash Price	$1,734.40
Rate for Payer: Medical Associates Commercial	$1,626.00
Rate for Payer: Midlands Choice Commercial	$1,517.60
Rate for Payer: Partners Health Alliance Commercial	$1,626.00
Rate for Payer: United Healthcare Commercial	$968.70

44955 APPENDECTOMY W/OTHER PROC

Professional

Both

$285.00

Service Code	CPT 44955
Hospital Charge Code	8069018
Hospital Revenue Code	975
Min. Negotiated Rate	$126.56
Max. Negotiated Rate	$213.75
Rate for Payer: Cash Price	$228.00
Rate for Payer: Cash Price	$228.00
Rate for Payer: Medical Associates Commercial	$213.75
Rate for Payer: Midlands Choice Commercial	$199.50
Rate for Payer: Partners Health Alliance Commercial	$213.75
Rate for Payer: United Healthcare Commercial	$126.56

44960 APPENDECTOMY OPEN RUPTURED

Professional

Both

$2,953.00

Service Code	CPT 44960
Hospital Charge Code	8069094
Hospital Revenue Code	975
Min. Negotiated Rate	$1,320.59
Max. Negotiated Rate	$2,214.75
Rate for Payer: Cash Price	$2,362.40
Rate for Payer: Cash Price	$2,362.40
Rate for Payer: Medical Associates Commercial	$2,214.75
Rate for Payer: Midlands Choice Commercial	$2,067.10
Rate for Payer: Partners Health Alliance Commercial	$2,214.75
Rate for Payer: United Healthcare Commercial	$1,320.59

44970 APPENDECTOMY LAPAROSCOPIC

Professional

Both

$2,027.00

Service Code	CPT 44970
Hospital Charge Code	8069095
Hospital Revenue Code	975
Min. Negotiated Rate	$904.83
Max. Negotiated Rate	$1,520.25
Rate for Payer: Cash Price	$1,621.60
Rate for Payer: Cash Price	$1,621.60
Rate for Payer: Medical Associates Commercial	$1,520.25
Rate for Payer: Midlands Choice Commercial	$1,418.90
Rate for Payer: Partners Health Alliance Commercial	$1,520.25
Rate for Payer: United Healthcare Commercial	$904.83

Know your out-of-pocket cost for care.

All Charges