Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

45110 ABDOMINAL PERINIAL RESECTION

Professional

Both

$6,244.00

Service Code	CPT 45110
Hospital Charge Code	8069103
Hospital Revenue Code	975
Min. Negotiated Rate	$2,792.14
Max. Negotiated Rate	$4,683.00
Rate for Payer: Cash Price	$4,995.20
Rate for Payer: Cash Price	$4,995.20
Rate for Payer: Medical Associates Commercial	$4,683.00
Rate for Payer: Midlands Choice Commercial	$4,370.80
Rate for Payer: Partners Health Alliance Commercial	$4,683.00
Rate for Payer: United Healthcare Commercial	$2,792.14

45330 SIGMOIDOSCOPY DX

Professional

Both

$336.00

Service Code	CPT 45330
Hospital Charge Code	8384949
Hospital Revenue Code	975
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$262.26
Rate for Payer: Cash Price	$268.80
Rate for Payer: Cash Price	$268.80
Rate for Payer: Medical Associates Commercial	$252.00
Rate for Payer: Midlands Choice Commercial	$235.20
Rate for Payer: Partners Health Alliance Commercial	$252.00
Rate for Payer: United Healthcare Commercial	$262.26

45331 SIGMOIDOSCOPY W/ BX (COLD FORECPS)

Professional

Both

$848.00

Service Code	CPT 45331
Hospital Charge Code	8384950
Hospital Revenue Code	975
Min. Negotiated Rate	$412.58
Max. Negotiated Rate	$636.00
Rate for Payer: Cash Price	$678.40
Rate for Payer: Cash Price	$678.40
Rate for Payer: Medical Associates Commercial	$636.00
Rate for Payer: Midlands Choice Commercial	$593.60
Rate for Payer: Partners Health Alliance Commercial	$636.00
Rate for Payer: United Healthcare Commercial	$412.58

45333 SIGMOIDOSCOPY POLYPECTOMY

Professional

Both

$972.00

Service Code	CPT 45333
Hospital Charge Code	8384948
Hospital Revenue Code	975
Min. Negotiated Rate	$469.36
Max. Negotiated Rate	$729.00
Rate for Payer: Cash Price	$777.60
Rate for Payer: Cash Price	$777.60
Rate for Payer: Medical Associates Commercial	$729.00
Rate for Payer: Midlands Choice Commercial	$680.40
Rate for Payer: Partners Health Alliance Commercial	$729.00
Rate for Payer: United Healthcare Commercial	$469.36

45334 Sigmoidoscopy w/ control of bleeding (any method)

Professional

Both

$1,793.00

Service Code	CPT 45334
Hospital Charge Code	8799178
Hospital Revenue Code	975
Min. Negotiated Rate	$791.49
Max. Negotiated Rate	$1,344.75
Rate for Payer: Cash Price	$1,434.40
Rate for Payer: Cash Price	$1,434.40
Rate for Payer: Medical Associates Commercial	$1,344.75
Rate for Payer: Midlands Choice Commercial	$1,255.10
Rate for Payer: Partners Health Alliance Commercial	$1,344.75
Rate for Payer: United Healthcare Commercial	$791.49

45338 SIGMOIDOSCOPY W/ SNARE POLYPECTOMY (HOT OR COLD SNARE)

Professional

Both

$890.00

Service Code	CPT 45338
Hospital Charge Code	8384951
Hospital Revenue Code	975
Min. Negotiated Rate	$426.42
Max. Negotiated Rate	$667.50
Rate for Payer: Cash Price	$712.00
Rate for Payer: Cash Price	$712.00
Rate for Payer: Medical Associates Commercial	$667.50
Rate for Payer: Midlands Choice Commercial	$623.00
Rate for Payer: Partners Health Alliance Commercial	$667.50
Rate for Payer: United Healthcare Commercial	$426.42

45378 COLONOSCOPY DX (NO BX)

Professional

Both

$1,049.00

Service Code	CPT 45378
Hospital Charge Code	8051989
Hospital Revenue Code	975
Min. Negotiated Rate	$499.42
Max. Negotiated Rate	$786.75
Rate for Payer: Cash Price	$839.20
Rate for Payer: Cash Price	$839.20
Rate for Payer: Medical Associates Commercial	$786.75
Rate for Payer: Midlands Choice Commercial	$734.30
Rate for Payer: Partners Health Alliance Commercial	$786.75
Rate for Payer: United Healthcare Commercial	$499.42

45380 COLONOSCOPY W/ BX (COLD FORCEPS)

Professional

Both

$1,341.00

Service Code	CPT 45380
Hospital Charge Code	8069193
Hospital Revenue Code	975
Min. Negotiated Rate	$642.98
Max. Negotiated Rate	$1,005.75
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Medical Associates Commercial	$1,005.75
Rate for Payer: Midlands Choice Commercial	$938.70
Rate for Payer: Partners Health Alliance Commercial	$1,005.75
Rate for Payer: United Healthcare Commercial	$642.98

45381 COLONOSCOPY W/ DIRECT SUBMUCOSAL INJ (TATTOOING)

Professional

Both

$1,282.00

Service Code	CPT 45381
Hospital Charge Code	8069152
Hospital Revenue Code	975
Min. Negotiated Rate	$638.26
Max. Negotiated Rate	$961.50
Rate for Payer: Cash Price	$1,025.60
Rate for Payer: Cash Price	$1,025.60
Rate for Payer: Medical Associates Commercial	$961.50
Rate for Payer: Midlands Choice Commercial	$897.40
Rate for Payer: Partners Health Alliance Commercial	$961.50
Rate for Payer: United Healthcare Commercial	$638.26

45382 Colonoscopy w control of bleeding any method

Professional

Both

$2,360.00

Service Code	CPT 45382
Hospital Charge Code	8799180
Hospital Revenue Code	975
Min. Negotiated Rate	$1,059.31
Max. Negotiated Rate	$1,770.00
Rate for Payer: Cash Price	$1,888.00
Rate for Payer: Cash Price	$1,888.00
Rate for Payer: Medical Associates Commercial	$1,770.00
Rate for Payer: Midlands Choice Commercial	$1,652.00
Rate for Payer: Partners Health Alliance Commercial	$1,770.00
Rate for Payer: United Healthcare Commercial	$1,059.31

45384 COLONOSCOPY W/ DESTRUCT/CAUT OF POLIP (HOT BX FORCEPS)

Professional

Both

$1,488.00

Service Code	CPT 45384
Hospital Charge Code	8069190
Hospital Revenue Code	975
Min. Negotiated Rate	$714.85
Max. Negotiated Rate	$1,116.00
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Medical Associates Commercial	$1,116.00
Rate for Payer: Midlands Choice Commercial	$1,041.60
Rate for Payer: Partners Health Alliance Commercial	$1,116.00
Rate for Payer: United Healthcare Commercial	$714.85

45385 COLONOSCOPY W/ SNARE POLYPECTOMY (HOT OR COLD SNARE)

Professional

Both

$1,410.00

Service Code	CPT 45385
Hospital Charge Code	8069017
Hospital Revenue Code	975
Min. Negotiated Rate	$673.60
Max. Negotiated Rate	$1,057.50
Rate for Payer: Cash Price	$1,128.00
Rate for Payer: Cash Price	$1,128.00
Rate for Payer: Medical Associates Commercial	$1,057.50
Rate for Payer: Midlands Choice Commercial	$987.00
Rate for Payer: Partners Health Alliance Commercial	$1,057.50
Rate for Payer: United Healthcare Commercial	$673.60

45398 Colonoscopy flexible w/ band ligation of hemorrhoids

Professional

Both

$2,274.00

Service Code	CPT 45398
Hospital Charge Code	8799181
Hospital Revenue Code	975
Min. Negotiated Rate	$1,176.85
Max. Negotiated Rate	$1,705.50
Rate for Payer: Cash Price	$1,819.20
Rate for Payer: Cash Price	$1,819.20
Rate for Payer: Medical Associates Commercial	$1,705.50
Rate for Payer: Midlands Choice Commercial	$1,591.80
Rate for Payer: Partners Health Alliance Commercial	$1,705.50
Rate for Payer: United Healthcare Commercial	$1,176.85

45915 Removal fecal impaction or foreign body

Professional

Both

$1,120.00

Service Code	CPT 45915
Hospital Charge Code	8799182
Hospital Revenue Code	975
Min. Negotiated Rate	$520.56
Max. Negotiated Rate	$840.00
Rate for Payer: Cash Price	$896.00
Rate for Payer: Cash Price	$896.00
Rate for Payer: Medical Associates Commercial	$840.00
Rate for Payer: Midlands Choice Commercial	$784.00
Rate for Payer: Partners Health Alliance Commercial	$840.00
Rate for Payer: United Healthcare Commercial	$520.56

4.5MM X 34MM HEADED SHORT THREAD SCREW

Facility

$540.00

Service Code	HCPCS C1713
Hospital Charge Code	8955183
Hospital Revenue Code	278
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$486.00
Rate for Payer: Aetna of IA Commercial	$486.00
Rate for Payer: Aetna of IA Medical Rental Products	$486.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.00
Rate for Payer: Medical Associates Commercial	$405.00
Rate for Payer: Midlands Choice Commercial	$378.00
Rate for Payer: United Healthcare Commercial	$486.00

4.5MM X 34MM HEADED SHORT THREAD SCREW

Facility

$540.00

Service Code	HCPCS C1713
Hospital Charge Code	8955183
Hospital Revenue Code	278
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$486.00
Rate for Payer: Aetna of IA Commercial	$486.00
Rate for Payer: Aetna of IA Medical Rental Products	$486.00
Rate for Payer: Aetna of IA Medicare	$307.80
Rate for Payer: Amerigroup Medicaid	$311.47
Rate for Payer: Amerigroup Medicare	$245.43
Rate for Payer: Cash Price	$432.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$243.00
Rate for Payer: Iowa Total Care Managed Medicaid	$308.45
Rate for Payer: Medical Associates Commercial	$405.00
Rate for Payer: Medical Associates Managed Medicare	$243.00
Rate for Payer: Midlands Choice Commercial	$378.00
Rate for Payer: Molina Healthcare Managed Medicaid	$312.98
Rate for Payer: Partners Health Alliance Commercial	$279.45
Rate for Payer: United Healthcare Commercial	$486.00
Rate for Payer: United Healthcare Managed Medicare	$318.60

4.5mm x 36mm HEADED SHORT THREAD SCREW

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8955185
Hospital Revenue Code	278
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Aetna of IA Medicare	$179.55
Rate for Payer: Amerigroup Medicaid	$181.69
Rate for Payer: Amerigroup Medicare	$143.17
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$141.75
Rate for Payer: Iowa Total Care Managed Medicaid	$179.93
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Medical Associates Managed Medicare	$141.75
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: Molina Healthcare Managed Medicaid	$182.57
Rate for Payer: Partners Health Alliance Commercial	$163.01
Rate for Payer: United Healthcare Commercial	$283.50
Rate for Payer: United Healthcare Managed Medicare	$185.85

4.5mm x 36mm HEADED SHORT THREAD SCREW

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8955185
Hospital Revenue Code	278
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: United Healthcare Commercial	$283.50

4.5 X 32mm STTCS HEADED SHORT THREAD SCREW

Facility

$513.00

Service Code	HCPCS C1713
Hospital Charge Code	8829097
Hospital Revenue Code	278
Min. Negotiated Rate	$230.85
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of IA Commercial	$461.70
Rate for Payer: Aetna of IA Medical Rental Products	$461.70
Rate for Payer: Aetna of IA Medicare	$292.41
Rate for Payer: Amerigroup Medicaid	$295.90
Rate for Payer: Amerigroup Medicare	$233.16
Rate for Payer: Cash Price	$410.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$384.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$230.85
Rate for Payer: Iowa Total Care Managed Medicaid	$293.03
Rate for Payer: Medical Associates Commercial	$384.75
Rate for Payer: Medical Associates Managed Medicare	$230.85
Rate for Payer: Midlands Choice Commercial	$359.10
Rate for Payer: Molina Healthcare Managed Medicaid	$297.33
Rate for Payer: Partners Health Alliance Commercial	$265.48
Rate for Payer: United Healthcare Commercial	$461.70
Rate for Payer: United Healthcare Managed Medicare	$302.67

4.5 X 32mm STTCS HEADED SHORT THREAD SCREW

Facility

$513.00

Service Code	HCPCS C1713
Hospital Charge Code	8829097
Hospital Revenue Code	278
Min. Negotiated Rate	$359.10
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of IA Commercial	$461.70
Rate for Payer: Aetna of IA Medical Rental Products	$461.70
Rate for Payer: Cash Price	$410.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$384.75
Rate for Payer: Medical Associates Commercial	$384.75
Rate for Payer: Midlands Choice Commercial	$359.10
Rate for Payer: United Healthcare Commercial	$461.70

4.5x38MM STTCS HEADED SHORT THREAD SCREW

Facility

$540.00

Service Code	HCPCS C1713
Hospital Charge Code	8758579
Hospital Revenue Code	278
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$486.00
Rate for Payer: Aetna of IA Commercial	$486.00
Rate for Payer: Aetna of IA Medical Rental Products	$486.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.00
Rate for Payer: Medical Associates Commercial	$405.00
Rate for Payer: Midlands Choice Commercial	$378.00
Rate for Payer: United Healthcare Commercial	$486.00

4.5x38MM STTCS HEADED SHORT THREAD SCREW

Facility

$540.00

Service Code	HCPCS C1713
Hospital Charge Code	8758579
Hospital Revenue Code	278
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$486.00
Rate for Payer: Aetna of IA Commercial	$486.00
Rate for Payer: Aetna of IA Medical Rental Products	$486.00
Rate for Payer: Aetna of IA Medicare	$307.80
Rate for Payer: Amerigroup Medicaid	$311.47
Rate for Payer: Amerigroup Medicare	$245.43
Rate for Payer: Cash Price	$432.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$243.00
Rate for Payer: Iowa Total Care Managed Medicaid	$308.45
Rate for Payer: Medical Associates Commercial	$405.00
Rate for Payer: Medical Associates Managed Medicare	$243.00
Rate for Payer: Midlands Choice Commercial	$378.00
Rate for Payer: Molina Healthcare Managed Medicaid	$312.98
Rate for Payer: Partners Health Alliance Commercial	$279.45
Rate for Payer: United Healthcare Commercial	$486.00
Rate for Payer: United Healthcare Managed Medicare	$318.60

4.5 X 40MM LTTCS HEADED LONG THREAD SCREWS

Facility

$513.00

Service Code	HCPCS C1713
Hospital Charge Code	8812782
Hospital Revenue Code	278
Min. Negotiated Rate	$359.10
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of IA Commercial	$461.70
Rate for Payer: Aetna of IA Medical Rental Products	$461.70
Rate for Payer: Cash Price	$410.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$384.75
Rate for Payer: Medical Associates Commercial	$384.75
Rate for Payer: Midlands Choice Commercial	$359.10
Rate for Payer: United Healthcare Commercial	$461.70

4.5 X 40MM LTTCS HEADED LONG THREAD SCREWS

Facility

$513.00

Service Code	HCPCS C1713
Hospital Charge Code	8812782
Hospital Revenue Code	278
Min. Negotiated Rate	$230.85
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of IA Commercial	$461.70
Rate for Payer: Aetna of IA Medical Rental Products	$461.70
Rate for Payer: Aetna of IA Medicare	$292.41
Rate for Payer: Amerigroup Medicaid	$295.90
Rate for Payer: Amerigroup Medicare	$233.16
Rate for Payer: Cash Price	$410.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$384.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$230.85
Rate for Payer: Iowa Total Care Managed Medicaid	$293.03
Rate for Payer: Medical Associates Commercial	$384.75
Rate for Payer: Medical Associates Managed Medicare	$230.85
Rate for Payer: Midlands Choice Commercial	$359.10
Rate for Payer: Molina Healthcare Managed Medicaid	$297.33
Rate for Payer: Partners Health Alliance Commercial	$265.48
Rate for Payer: United Healthcare Commercial	$461.70
Rate for Payer: United Healthcare Managed Medicare	$302.67

4.5x45MM STTCS HEADED SHORT THREAD SCREW

Facility

$513.00

Service Code	HCPCS C1713
Hospital Charge Code	8824136
Hospital Revenue Code	278
Min. Negotiated Rate	$359.10
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of IA Commercial	$461.70
Rate for Payer: Aetna of IA Medical Rental Products	$461.70
Rate for Payer: Cash Price	$410.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$384.75
Rate for Payer: Medical Associates Commercial	$384.75
Rate for Payer: Midlands Choice Commercial	$359.10
Rate for Payer: United Healthcare Commercial	$461.70

Know your out-of-pocket cost for care.

All Charges