Van Diest Medical Center

All Charges

Charge

Type

Price

49650 HERNIA REPR INGUINAL LAP INIT

Professional

$1,443.00

Service Code	CPT 49650
Hospital Charge Code	8069013
Hospital Revenue Code	975
Min. Negotiated Rate	$386.31
Max. Negotiated Rate	$1,010.10
Rate for Payer: Aetna of IA Medicare	$386.31
Rate for Payer: Amerigroup Medicaid	$399.44
Rate for Payer: Cash Price	$1,154.40
Rate for Payer: Cash Price	$1,154.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$463.57
Rate for Payer: Iowa Total Care Managed Medicaid	$394.04
Rate for Payer: Medical Associates Commercial	$733.99
Rate for Payer: Medical Associates Managed Medicare	$386.31
Rate for Payer: Midlands Choice Commercial	$1,010.10
Rate for Payer: Partners Health Alliance Commercial	$579.46
Rate for Payer: Wellmark IA HMO	$828.00
Rate for Payer: Wellmark IA PPO	$972.00

49651 HERNIA REPR INGUINAL LAP RECUR

Professional

$1,876.00

Service Code	CPT 49651
Hospital Charge Code	8069057
Hospital Revenue Code	975
Min. Negotiated Rate	$503.88
Max. Negotiated Rate	$1,313.20
Rate for Payer: Aetna of IA Medicare	$503.88
Rate for Payer: Amerigroup Medicaid	$521.01
Rate for Payer: Cash Price	$1,500.80
Rate for Payer: Cash Price	$1,500.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$604.66
Rate for Payer: Iowa Total Care Managed Medicaid	$513.96
Rate for Payer: Medical Associates Commercial	$957.37
Rate for Payer: Medical Associates Managed Medicare	$503.88
Rate for Payer: Midlands Choice Commercial	$1,313.20
Rate for Payer: Partners Health Alliance Commercial	$755.82
Rate for Payer: Wellmark IA HMO	$1,082.00
Rate for Payer: Wellmark IA PPO	$1,270.00

49652 HERNIA REPAIR LAP VENT/ABD

Professional

$2,509.00

Service Code	CPT 49652
Hospital Charge Code	8069066
Hospital Revenue Code	975
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$1,756.30
Rate for Payer: Cash Price	$2,007.20
Rate for Payer: Cash Price	$2,007.20
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$1,756.30
Rate for Payer: Wellmark IA HMO	$1,356.00
Rate for Payer: Wellmark IA PPO	$1,596.00

49653 Laparoscopic repair ventral umbilical epigastric hernia w/mesh; incarcerated

Professional

$3,159.00

Service Code	CPT 49653
Hospital Charge Code	8799194
Hospital Revenue Code	975
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$2,211.30
Rate for Payer: Cash Price	$2,527.20
Rate for Payer: Cash Price	$2,527.20
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$2,211.30
Rate for Payer: Wellmark IA HMO	$1,699.00
Rate for Payer: Wellmark IA PPO	$1,999.00

49654 Laparoscopic surgical repair incisional hernia reducible

Professional

$2,853.00

Service Code	CPT 49654
Hospital Charge Code	8799195
Hospital Revenue Code	975
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$1,997.10
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$1,997.10
Rate for Payer: Wellmark IA HMO	$1,539.00
Rate for Payer: Wellmark IA PPO	$1,810.00

4-HOLE CUSTOM PLATE

Facility IP

$2,178.00

Service Code	CPT C1713
Hospital Charge Code	8759892
Hospital Revenue Code	278
Min. Negotiated Rate	$1,524.60
Max. Negotiated Rate	$1,960.20
Rate for Payer: Aetna of IA Commercial	$1,960.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,960.20
Rate for Payer: Cash Price	$1,742.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,633.50
Rate for Payer: Medical Associates Commercial	$1,633.50
Rate for Payer: Midlands Choice Commercial	$1,524.60
Rate for Payer: United Healthcare Commercial	$1,960.20

4-HOLE CUSTOM PLATE

Facility OP

$2,178.00

Service Code	CPT C1713
Hospital Charge Code	8759892
Hospital Revenue Code	278
Min. Negotiated Rate	$1,088.56
Max. Negotiated Rate	$1,960.20
Rate for Payer: Aetna of IA Commercial	$1,960.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,960.20
Rate for Payer: Aetna of IA Medicare	$1,241.46
Rate for Payer: Amerigroup Medicaid	$1,099.24
Rate for Payer: Amerigroup Medicare	$1,099.89
Rate for Payer: Cash Price	$1,742.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,633.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,089.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,088.56
Rate for Payer: Medical Associates Commercial	$1,633.50
Rate for Payer: Medical Associates Managed Medicare	$1,089.00
Rate for Payer: Midlands Choice Commercial	$1,524.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1,105.34
Rate for Payer: Partners Health Alliance Commercial	$1,633.50
Rate for Payer: United Healthcare Commercial	$1,960.20
Rate for Payer: United Healthcare Managed Medicare	$1,285.02

51040 CATH SUPERPUBIC

Professional

$974.00

Service Code	CPT 51040
Hospital Charge Code	8068976
Hospital Revenue Code	975
Min. Negotiated Rate	$267.66
Max. Negotiated Rate	$681.80
Rate for Payer: Aetna of IA Medicare	$267.66
Rate for Payer: Amerigroup Medicaid	$276.76
Rate for Payer: Cash Price	$779.20
Rate for Payer: Cash Price	$779.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$321.19
Rate for Payer: Iowa Total Care Managed Medicaid	$273.01
Rate for Payer: Medical Associates Commercial	$508.55
Rate for Payer: Medical Associates Managed Medicare	$267.66
Rate for Payer: Midlands Choice Commercial	$681.80
Rate for Payer: Partners Health Alliance Commercial	$401.49
Rate for Payer: Wellmark IA HMO	$550.00
Rate for Payer: Wellmark IA PPO	$646.00

51705 CYSTOSTOMY TUBE CHANGE SIMPLE

Professional

$302.00

Service Code	CPT 51705
Hospital Charge Code	8069096
Hospital Revenue Code	975
Min. Negotiated Rate	$46.96
Max. Negotiated Rate	$211.40
Rate for Payer: Aetna of IA Medicare	$46.96
Rate for Payer: Amerigroup Medicaid	$48.56
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.35
Rate for Payer: Iowa Total Care Managed Medicaid	$47.90
Rate for Payer: Medical Associates Commercial	$89.22
Rate for Payer: Medical Associates Managed Medicare	$46.96
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: Partners Health Alliance Commercial	$70.44
Rate for Payer: Wellmark IA HMO	$97.00
Rate for Payer: Wellmark IA PPO	$114.00

51725 SIMPLE CYSTOMETROGRAM

Professional

$621.00

Service Code	CPT 51725
Hospital Charge Code	8068956
Hospital Revenue Code	975
Min. Negotiated Rate	$205.80
Max. Negotiated Rate	$513.00
Rate for Payer: Aetna of IA Medicare	$205.80
Rate for Payer: Amerigroup Medicaid	$212.80
Rate for Payer: Cash Price	$496.80
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$246.96
Rate for Payer: Iowa Total Care Managed Medicaid	$209.92
Rate for Payer: Medical Associates Commercial	$391.02
Rate for Payer: Medical Associates Managed Medicare	$205.80
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: Partners Health Alliance Commercial	$308.70
Rate for Payer: Wellmark IA HMO	$437.00
Rate for Payer: Wellmark IA PPO	$513.00

54001 SLIT PREPUCE DORSAL OR LAT; NOT NEWBORN

Professional

$616.00

Service Code	CPT 54001
Hospital Charge Code	8068957
Hospital Revenue Code	975
Min. Negotiated Rate	$128.81
Max. Negotiated Rate	$431.20
Rate for Payer: Aetna of IA Medicare	$128.81
Rate for Payer: Amerigroup Medicaid	$133.19
Rate for Payer: Cash Price	$492.80
Rate for Payer: Cash Price	$492.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$154.57
Rate for Payer: Iowa Total Care Managed Medicaid	$131.39
Rate for Payer: Medical Associates Commercial	$244.74
Rate for Payer: Medical Associates Managed Medicare	$128.81
Rate for Payer: Midlands Choice Commercial	$431.20
Rate for Payer: Partners Health Alliance Commercial	$193.22
Rate for Payer: Wellmark IA HMO	$265.00
Rate for Payer: Wellmark IA PPO	$311.00

54161 CIRCUMCISION OR

Professional

$663.00

Service Code	CPT 54161
Hospital Charge Code	8068980
Hospital Revenue Code	975
Min. Negotiated Rate	$180.47
Max. Negotiated Rate	$464.10
Rate for Payer: Aetna of IA Medicare	$180.47
Rate for Payer: Amerigroup Medicaid	$186.61
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$216.56
Rate for Payer: Iowa Total Care Managed Medicaid	$184.08
Rate for Payer: Medical Associates Commercial	$342.89
Rate for Payer: Medical Associates Managed Medicare	$180.47
Rate for Payer: Midlands Choice Commercial	$464.10
Rate for Payer: Partners Health Alliance Commercial	$270.70
Rate for Payer: Wellmark IA HMO	$372.00
Rate for Payer: Wellmark IA PPO	$437.00

54520 ORCHIECTOMY

Professional

$1,099.00

Service Code	CPT 54520
Hospital Charge Code	8300879
Hospital Revenue Code	975
Min. Negotiated Rate	$300.01
Max. Negotiated Rate	$769.30
Rate for Payer: Aetna of IA Medicare	$300.01
Rate for Payer: Amerigroup Medicaid	$310.21
Rate for Payer: Cash Price	$879.20
Rate for Payer: Cash Price	$879.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$360.01
Rate for Payer: Iowa Total Care Managed Medicaid	$306.01
Rate for Payer: Medical Associates Commercial	$570.02
Rate for Payer: Medical Associates Managed Medicare	$300.01
Rate for Payer: Midlands Choice Commercial	$769.30
Rate for Payer: Partners Health Alliance Commercial	$450.02
Rate for Payer: Wellmark IA HMO	$620.00
Rate for Payer: Wellmark IA PPO	$728.00

54700 IncisionDrainage- epididymis testis/scrotum

Professional

$719.00

Service Code	CPT 54700
Hospital Charge Code	8799197
Hospital Revenue Code	975
Min. Negotiated Rate	$194.50
Max. Negotiated Rate	$503.30
Rate for Payer: Aetna of IA Medicare	$194.50
Rate for Payer: Amerigroup Medicaid	$201.11
Rate for Payer: Cash Price	$575.20
Rate for Payer: Cash Price	$575.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$233.40
Rate for Payer: Iowa Total Care Managed Medicaid	$198.39
Rate for Payer: Medical Associates Commercial	$369.55
Rate for Payer: Medical Associates Managed Medicare	$194.50
Rate for Payer: Midlands Choice Commercial	$503.30
Rate for Payer: Partners Health Alliance Commercial	$291.75
Rate for Payer: Wellmark IA HMO	$401.00
Rate for Payer: Wellmark IA PPO	$471.00

55100 Drainage scrotal wall abscess

Professional

$750.00

Service Code	CPT 55100
Hospital Charge Code	8799198
Hospital Revenue Code	975
Min. Negotiated Rate	$153.17
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna of IA Medicare	$153.17
Rate for Payer: Amerigroup Medicaid	$158.38
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$183.80
Rate for Payer: Iowa Total Care Managed Medicaid	$156.23
Rate for Payer: Medical Associates Commercial	$291.02
Rate for Payer: Medical Associates Managed Medicare	$153.17
Rate for Payer: Midlands Choice Commercial	$525.00
Rate for Payer: Partners Health Alliance Commercial	$229.76
Rate for Payer: Wellmark IA HMO	$317.00
Rate for Payer: Wellmark IA PPO	$372.00

55520 EXCISE LESION OF SPERMATIC CORD

Professional

$1,526.00

Service Code	CPT 55520
Hospital Charge Code	8069128
Hospital Revenue Code	975
Min. Negotiated Rate	$409.73
Max. Negotiated Rate	$1,068.20
Rate for Payer: Aetna of IA Medicare	$409.73
Rate for Payer: Amerigroup Medicaid	$423.66
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$491.68
Rate for Payer: Iowa Total Care Managed Medicaid	$417.92
Rate for Payer: Medical Associates Commercial	$778.49
Rate for Payer: Medical Associates Managed Medicare	$409.73
Rate for Payer: Midlands Choice Commercial	$1,068.20
Rate for Payer: Partners Health Alliance Commercial	$614.60
Rate for Payer: Wellmark IA HMO	$876.00
Rate for Payer: Wellmark IA PPO	$1,028.00

56405 Incision and drainage of vulva or perineal abscess

Professional

$189.00

Service Code	CPT 56405
Hospital Charge Code	8799223
Hospital Revenue Code	975
Min. Negotiated Rate	$115.61
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna of IA Medicare	$115.61
Rate for Payer: Amerigroup Medicaid	$119.54
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$138.73
Rate for Payer: Iowa Total Care Managed Medicaid	$117.92
Rate for Payer: Medical Associates Commercial	$219.66
Rate for Payer: Medical Associates Managed Medicare	$115.61
Rate for Payer: Midlands Choice Commercial	$132.30
Rate for Payer: Partners Health Alliance Commercial	$173.42
Rate for Payer: Wellmark IA HMO	$244.00
Rate for Payer: Wellmark IA PPO	$286.00

56440 Marsupialization of Bartholin's gland cyst

Professional

$602.00

Service Code	CPT 56440
Hospital Charge Code	8799224
Hospital Revenue Code	975
Min. Negotiated Rate	$165.19
Max. Negotiated Rate	$421.40
Rate for Payer: Aetna of IA Medicare	$165.19
Rate for Payer: Amerigroup Medicaid	$170.81
Rate for Payer: Cash Price	$481.60
Rate for Payer: Cash Price	$481.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$198.23
Rate for Payer: Iowa Total Care Managed Medicaid	$168.49
Rate for Payer: Medical Associates Commercial	$313.86
Rate for Payer: Medical Associates Managed Medicare	$165.19
Rate for Payer: Midlands Choice Commercial	$421.40
Rate for Payer: Partners Health Alliance Commercial	$247.78
Rate for Payer: Wellmark IA HMO	$346.00
Rate for Payer: Wellmark IA PPO	$406.00

56605 BX OF VULVA OR PERINEUM FIRST

Professional

$477.00

Service Code	CPT 56605
Hospital Charge Code	8068998
Hospital Revenue Code	975
Min. Negotiated Rate	$53.36
Max. Negotiated Rate	$333.90
Rate for Payer: Aetna of IA Medicare	$53.36
Rate for Payer: Amerigroup Medicaid	$55.17
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cash Price	$381.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.03
Rate for Payer: Iowa Total Care Managed Medicaid	$54.43
Rate for Payer: Medical Associates Commercial	$101.38
Rate for Payer: Medical Associates Managed Medicare	$53.36
Rate for Payer: Midlands Choice Commercial	$333.90
Rate for Payer: Partners Health Alliance Commercial	$80.04
Rate for Payer: Wellmark IA HMO	$106.00
Rate for Payer: Wellmark IA PPO	$124.00

56700 Partial hymenectomy or revision of hymenal ring

Professional

$628.00

Service Code	CPT 56700
Hospital Charge Code	8799199
Hospital Revenue Code	975
Min. Negotiated Rate	$184.93
Max. Negotiated Rate	$458.00
Rate for Payer: Aetna of IA Medicare	$184.93
Rate for Payer: Amerigroup Medicaid	$191.22
Rate for Payer: Cash Price	$502.40
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$221.92
Rate for Payer: Iowa Total Care Managed Medicaid	$188.63
Rate for Payer: Medical Associates Commercial	$351.37
Rate for Payer: Medical Associates Managed Medicare	$184.93
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: Partners Health Alliance Commercial	$277.40
Rate for Payer: Wellmark IA HMO	$391.00
Rate for Payer: Wellmark IA PPO	$458.00

57461 Colposcopy of cervix w/loop electrode conization of cervix

Professional

$1,149.00

Service Code	CPT 57461
Hospital Charge Code	8799200
Hospital Revenue Code	975
Min. Negotiated Rate	$164.79
Max. Negotiated Rate	$804.30
Rate for Payer: Aetna of IA Medicare	$164.79
Rate for Payer: Amerigroup Medicaid	$170.39
Rate for Payer: Cash Price	$919.20
Rate for Payer: Cash Price	$919.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$197.75
Rate for Payer: Iowa Total Care Managed Medicaid	$168.09
Rate for Payer: Medical Associates Commercial	$313.10
Rate for Payer: Medical Associates Managed Medicare	$164.79
Rate for Payer: Midlands Choice Commercial	$804.30
Rate for Payer: Partners Health Alliance Commercial	$247.18
Rate for Payer: Wellmark IA HMO	$348.00
Rate for Payer: Wellmark IA PPO	$408.00

58100 ENDOMETRIAL BX W/O CERVICAL DILATION

Professional

$362.00

Service Code	CPT 58100
Hospital Charge Code	8378877
Hospital Revenue Code	975
Min. Negotiated Rate	$56.96
Max. Negotiated Rate	$253.40
Rate for Payer: Aetna of IA Medicare	$56.96
Rate for Payer: Amerigroup Medicaid	$58.90
Rate for Payer: Cash Price	$289.60
Rate for Payer: Cash Price	$289.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$68.35
Rate for Payer: Iowa Total Care Managed Medicaid	$58.10
Rate for Payer: Medical Associates Commercial	$108.22
Rate for Payer: Medical Associates Managed Medicare	$56.96
Rate for Payer: Midlands Choice Commercial	$253.40
Rate for Payer: Partners Health Alliance Commercial	$85.44
Rate for Payer: Wellmark IA HMO	$120.00
Rate for Payer: Wellmark IA PPO	$141.00

58120 DC DIAGNOSTIC OR TEHERAP NOT OB

Professional

$856.00

Service Code	CPT 58120
Hospital Charge Code	8069166
Hospital Revenue Code	975
Min. Negotiated Rate	$212.33
Max. Negotiated Rate	$599.20
Rate for Payer: Aetna of IA Medicare	$212.33
Rate for Payer: Amerigroup Medicaid	$219.55
Rate for Payer: Cash Price	$684.80
Rate for Payer: Cash Price	$684.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$254.80
Rate for Payer: Iowa Total Care Managed Medicaid	$216.58
Rate for Payer: Medical Associates Commercial	$403.43
Rate for Payer: Medical Associates Managed Medicare	$212.33
Rate for Payer: Midlands Choice Commercial	$599.20
Rate for Payer: Partners Health Alliance Commercial	$318.50
Rate for Payer: Wellmark IA HMO	$447.00
Rate for Payer: Wellmark IA PPO	$524.00

58300 IUD INSERTION

Professional

$240.00

Service Code	CPT 58300
Hospital Charge Code	8069024
Hospital Revenue Code	975
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$168.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$168.00
Rate for Payer: Wellmark IA HMO	$96.00
Rate for Payer: Wellmark IA PPO	$112.00

58340 Catheterization/introduction of saline/contrast during hysterosalpingography

Professional

$645.00

Service Code	CPT 58340
Hospital Charge Code	8799201
Hospital Revenue Code	975
Min. Negotiated Rate	$52.14
Max. Negotiated Rate	$451.50
Rate for Payer: Aetna of IA Medicare	$52.14
Rate for Payer: Amerigroup Medicaid	$53.91
Rate for Payer: Cash Price	$516.00
Rate for Payer: Cash Price	$516.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$62.57
Rate for Payer: Iowa Total Care Managed Medicaid	$53.18
Rate for Payer: Medical Associates Commercial	$99.07
Rate for Payer: Medical Associates Managed Medicare	$52.14
Rate for Payer: Midlands Choice Commercial	$451.50
Rate for Payer: Partners Health Alliance Commercial	$78.21
Rate for Payer: Wellmark IA HMO	$107.00
Rate for Payer: Wellmark IA PPO	$126.00

Price Transparency.

All Charges