Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

58350 Chromotubation of oviduct

Professional

Both

$422.00

Service Code	CPT 58350
Hospital Charge Code	8799202
Hospital Revenue Code	975
Min. Negotiated Rate	$86.43
Max. Negotiated Rate	$295.40
Rate for Payer: Aetna of IA Medicare	$86.43
Rate for Payer: Amerigroup Medicaid	$89.37
Rate for Payer: Cash Price	$337.60
Rate for Payer: Cash Price	$337.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.72
Rate for Payer: Iowa Total Care Managed Medicaid	$88.16
Rate for Payer: Medical Associates Commercial	$164.22
Rate for Payer: Medical Associates Managed Medicare	$86.43
Rate for Payer: Midlands Choice Commercial	$295.40
Rate for Payer: Oscar Health of IA Commercial	$149.52
Rate for Payer: Partners Health Alliance Commercial	$129.64

58561 Hysteroscopy surgical; w/ removal of leiomyomata

Professional

Both

$1,201.00

Service Code	CPT 58561
Hospital Charge Code	8799203
Hospital Revenue Code	975
Min. Negotiated Rate	$321.81
Max. Negotiated Rate	$840.70
Rate for Payer: Aetna of IA Medicare	$321.81
Rate for Payer: Amerigroup Medicaid	$332.75
Rate for Payer: Cash Price	$960.80
Rate for Payer: Cash Price	$960.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$386.17
Rate for Payer: Iowa Total Care Managed Medicaid	$328.25
Rate for Payer: Medical Associates Commercial	$611.44
Rate for Payer: Medical Associates Managed Medicare	$321.81
Rate for Payer: Midlands Choice Commercial	$840.70
Rate for Payer: Oscar Health of IA Commercial	$556.73
Rate for Payer: Partners Health Alliance Commercial	$482.72

58600 TUBAL LIGATION

Professional

Both

$1,201.00

Service Code	CPT 58600
Hospital Charge Code	8068988
Hospital Revenue Code	975
Min. Negotiated Rate	$337.48
Max. Negotiated Rate	$840.70
Rate for Payer: Aetna of IA Medicare	$337.48
Rate for Payer: Amerigroup Medicaid	$348.95
Rate for Payer: Cash Price	$960.80
Rate for Payer: Cash Price	$960.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$404.98
Rate for Payer: Iowa Total Care Managed Medicaid	$344.23
Rate for Payer: Medical Associates Commercial	$641.21
Rate for Payer: Medical Associates Managed Medicare	$337.48
Rate for Payer: Midlands Choice Commercial	$840.70
Rate for Payer: Oscar Health of IA Commercial	$583.84
Rate for Payer: Partners Health Alliance Commercial	$506.22

58605 TUBAL LIGATION POST PARTUM

Professional

Both

$1,088.00

Service Code	CPT 58605
Hospital Charge Code	8068982
Hospital Revenue Code	975
Min. Negotiated Rate	$306.84
Max. Negotiated Rate	$761.60
Rate for Payer: Aetna of IA Medicare	$306.84
Rate for Payer: Amerigroup Medicaid	$317.27
Rate for Payer: Cash Price	$870.40
Rate for Payer: Cash Price	$870.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$368.21
Rate for Payer: Iowa Total Care Managed Medicaid	$312.98
Rate for Payer: Medical Associates Commercial	$583.00
Rate for Payer: Medical Associates Managed Medicare	$306.84
Rate for Payer: Midlands Choice Commercial	$761.60
Rate for Payer: Oscar Health of IA Commercial	$530.83
Rate for Payer: Partners Health Alliance Commercial	$460.26

58611 TUBAL LIGATION W/OTHER PROC

Professional

Both

$255.00

Service Code	CPT 58611
Hospital Charge Code	8069138
Hospital Revenue Code	975
Min. Negotiated Rate	$67.81
Max. Negotiated Rate	$178.50
Rate for Payer: Aetna of IA Medicare	$67.81
Rate for Payer: Amerigroup Medicaid	$70.12
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.37
Rate for Payer: Iowa Total Care Managed Medicaid	$69.17
Rate for Payer: Medical Associates Commercial	$128.84
Rate for Payer: Medical Associates Managed Medicare	$67.81
Rate for Payer: Midlands Choice Commercial	$178.50
Rate for Payer: Oscar Health of IA Commercial	$117.31
Rate for Payer: Partners Health Alliance Commercial	$101.72

58670 LAP TUBAL W/ DESTRUCTION OF OVIDUCTS

Professional

Both

$1,207.00

Service Code	CPT 58670
Hospital Charge Code	8069144
Hospital Revenue Code	975
Min. Negotiated Rate	$338.08
Max. Negotiated Rate	$844.90
Rate for Payer: Aetna of IA Medicare	$338.08
Rate for Payer: Amerigroup Medicaid	$349.57
Rate for Payer: Cash Price	$965.60
Rate for Payer: Cash Price	$965.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.70
Rate for Payer: Iowa Total Care Managed Medicaid	$344.84
Rate for Payer: Medical Associates Commercial	$642.35
Rate for Payer: Medical Associates Managed Medicare	$338.08
Rate for Payer: Midlands Choice Commercial	$844.90
Rate for Payer: Oscar Health of IA Commercial	$584.88
Rate for Payer: Partners Health Alliance Commercial	$507.12

58671 Laparoscopy surgical; w/ occlusion of oviducts by device

Professional

Both

$1,197.00

Service Code	CPT 58671
Hospital Charge Code	8799204
Hospital Revenue Code	975
Min. Negotiated Rate	$338.08
Max. Negotiated Rate	$837.90
Rate for Payer: Aetna of IA Medicare	$338.08
Rate for Payer: Amerigroup Medicaid	$349.57
Rate for Payer: Cash Price	$957.60
Rate for Payer: Cash Price	$957.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.70
Rate for Payer: Iowa Total Care Managed Medicaid	$344.84
Rate for Payer: Medical Associates Commercial	$642.35
Rate for Payer: Medical Associates Managed Medicare	$338.08
Rate for Payer: Midlands Choice Commercial	$837.90
Rate for Payer: Oscar Health of IA Commercial	$584.88
Rate for Payer: Partners Health Alliance Commercial	$507.12

58720 SALPINGO-OOPHORECTOMY

Professional

Both

$2,459.00

Service Code	CPT 58720
Hospital Charge Code	8069040
Hospital Revenue Code	975
Min. Negotiated Rate	$688.94
Max. Negotiated Rate	$1,721.30
Rate for Payer: Aetna of IA Medicare	$688.94
Rate for Payer: Amerigroup Medicaid	$712.36
Rate for Payer: Cash Price	$1,967.20
Rate for Payer: Cash Price	$1,967.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$826.73
Rate for Payer: Iowa Total Care Managed Medicaid	$702.72
Rate for Payer: Medical Associates Commercial	$1,308.99
Rate for Payer: Medical Associates Managed Medicare	$688.94
Rate for Payer: Midlands Choice Commercial	$1,721.30
Rate for Payer: Oscar Health of IA Commercial	$1,191.87
Rate for Payer: Partners Health Alliance Commercial	$1,033.41

58925 OVARIAN CYSTECTOMY W/HYSTERECT

Professional

Both

$2,484.00

Service Code	CPT 58925
Hospital Charge Code	8068997
Hospital Revenue Code	975
Min. Negotiated Rate	$693.00
Max. Negotiated Rate	$1,738.80
Rate for Payer: Aetna of IA Medicare	$693.00
Rate for Payer: Amerigroup Medicaid	$716.56
Rate for Payer: Cash Price	$1,987.20
Rate for Payer: Cash Price	$1,987.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$831.60
Rate for Payer: Iowa Total Care Managed Medicaid	$706.86
Rate for Payer: Medical Associates Commercial	$1,316.70
Rate for Payer: Medical Associates Managed Medicare	$693.00
Rate for Payer: Midlands Choice Commercial	$1,738.80
Rate for Payer: Oscar Health of IA Commercial	$1,198.89
Rate for Payer: Partners Health Alliance Commercial	$1,039.50

58940 OOPHORECTOMY

Professional

Both

$1,754.00

Service Code	CPT 58940
Hospital Charge Code	8069191
Hospital Revenue Code	975
Min. Negotiated Rate	$502.37
Max. Negotiated Rate	$1,227.80
Rate for Payer: Aetna of IA Medicare	$502.37
Rate for Payer: Amerigroup Medicaid	$519.45
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$602.84
Rate for Payer: Iowa Total Care Managed Medicaid	$512.42
Rate for Payer: Medical Associates Commercial	$954.50
Rate for Payer: Medical Associates Managed Medicare	$502.37
Rate for Payer: Midlands Choice Commercial	$1,227.80
Rate for Payer: Oscar Health of IA Commercial	$869.10
Rate for Payer: Partners Health Alliance Commercial	$753.56

59514 C-SECTION

Professional

Both

$3,100.00

Service Code	CPT 59514
Hospital Charge Code	8069081
Hospital Revenue Code	975
Min. Negotiated Rate	$788.63
Max. Negotiated Rate	$1,641.09
Rate for Payer: Aetna of IA Medicare	$788.63
Rate for Payer: Amerigroup Medicaid	$815.44
Rate for Payer: Cash Price	$2,480.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$946.36
Rate for Payer: Iowa Total Care Managed Medicaid	$804.40
Rate for Payer: Medical Associates Commercial	$1,498.40
Rate for Payer: Medical Associates Managed Medicare	$788.63
Rate for Payer: Midlands Choice Commercial	$1,641.09
Rate for Payer: Oscar Health of IA Commercial	$1,364.33
Rate for Payer: Partners Health Alliance Commercial	$1,182.94

59820 Treatment of missed abortion- 1st trimester

Professional

Both

$1,270.00

Service Code	CPT 59820
Hospital Charge Code	8799205
Hospital Revenue Code	975
Min. Negotiated Rate	$343.71
Max. Negotiated Rate	$889.00
Rate for Payer: Aetna of IA Medicare	$343.71
Rate for Payer: Amerigroup Medicaid	$355.40
Rate for Payer: Cash Price	$1,016.00
Rate for Payer: Cash Price	$1,016.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$412.45
Rate for Payer: Iowa Total Care Managed Medicaid	$350.58
Rate for Payer: Medical Associates Commercial	$653.05
Rate for Payer: Medical Associates Managed Medicare	$343.71
Rate for Payer: Midlands Choice Commercial	$889.00
Rate for Payer: Oscar Health of IA Commercial	$594.62
Rate for Payer: Partners Health Alliance Commercial	$515.56

60220 THYROID LOBECTOMY TOTAL

Professional

Both

$2,370.00

Service Code	CPT 60220
Hospital Charge Code	8068978
Hospital Revenue Code	975
Min. Negotiated Rate	$637.00
Max. Negotiated Rate	$1,659.00
Rate for Payer: Aetna of IA Medicare	$637.00
Rate for Payer: Amerigroup Medicaid	$658.66
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$764.40
Rate for Payer: Iowa Total Care Managed Medicaid	$649.74
Rate for Payer: Medical Associates Commercial	$1,210.30
Rate for Payer: Medical Associates Managed Medicare	$637.00
Rate for Payer: Midlands Choice Commercial	$1,659.00
Rate for Payer: Oscar Health of IA Commercial	$1,102.01
Rate for Payer: Partners Health Alliance Commercial	$955.50

62321 Spinal injection steroid- cervical/thoracic with fluoroscopic guidance

Professional

Both

$860.00

Service Code	CPT 62321
Hospital Charge Code	8799206
Hospital Revenue Code	975
Min. Negotiated Rate	$98.38
Max. Negotiated Rate	$230.16
Rate for Payer: Aetna of IA Medicare	$98.38
Rate for Payer: Amerigroup Medicaid	$101.72
Rate for Payer: Cash Price	$688.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.06
Rate for Payer: Iowa Total Care Managed Medicaid	$100.35
Rate for Payer: Medical Associates Commercial	$186.92
Rate for Payer: Medical Associates Managed Medicare	$98.38
Rate for Payer: Midlands Choice Commercial	$230.16
Rate for Payer: Oscar Health of IA Commercial	$170.20
Rate for Payer: Partners Health Alliance Commercial	$147.57

62323 Spinal injection steroid- lumbar/sacral with fluoroscopic guidance

Professional

Both

$808.00

Service Code	CPT 62323
Hospital Charge Code	8799211
Hospital Revenue Code	975
Min. Negotiated Rate	$90.93
Max. Negotiated Rate	$211.85
Rate for Payer: Aetna of IA Medicare	$90.93
Rate for Payer: Amerigroup Medicaid	$94.02
Rate for Payer: Cash Price	$646.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.12
Rate for Payer: Iowa Total Care Managed Medicaid	$92.75
Rate for Payer: Medical Associates Commercial	$172.77
Rate for Payer: Medical Associates Managed Medicare	$90.93
Rate for Payer: Midlands Choice Commercial	$211.85
Rate for Payer: Oscar Health of IA Commercial	$157.31
Rate for Payer: Partners Health Alliance Commercial	$136.40

6.25MM MALYUGIN RING

Facility

$157.50

Service Code	CPT C1713
Hospital Charge Code	8884865
Hospital Revenue Code	278
Min. Negotiated Rate	$78.72
Max. Negotiated Rate	$141.75
Rate for Payer: Aetna of IA Commercial	$141.75
Rate for Payer: Aetna of IA Medical Rental Products	$141.75
Rate for Payer: Aetna of IA Medicare	$89.78
Rate for Payer: Amerigroup Medicaid	$79.49
Rate for Payer: Amerigroup Medicare	$79.54
Rate for Payer: Cash Price	$126.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$78.75
Rate for Payer: Iowa Total Care Managed Medicaid	$78.72
Rate for Payer: Medical Associates Commercial	$118.12
Rate for Payer: Medical Associates Managed Medicare	$78.75
Rate for Payer: Midlands Choice Commercial	$110.25
Rate for Payer: Molina Healthcare Managed Medicaid	$79.93
Rate for Payer: Molina Healthcare Managed Medicare	$79.88
Rate for Payer: Oscar Health of IA Commercial	$118.12
Rate for Payer: Partners Health Alliance Commercial	$118.12
Rate for Payer: United Healthcare Commercial	$141.75
Rate for Payer: United Healthcare Managed Medicare	$92.92

6.25MM MALYUGIN RING

Facility

$157.50

Service Code	CPT C1713
Hospital Charge Code	8884865
Hospital Revenue Code	278
Min. Negotiated Rate	$110.25
Max. Negotiated Rate	$141.75
Rate for Payer: Aetna of IA Commercial	$141.75
Rate for Payer: Aetna of IA Medical Rental Products	$141.75
Rate for Payer: Cash Price	$126.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.12
Rate for Payer: Medical Associates Commercial	$118.12
Rate for Payer: Midlands Choice Commercial	$110.25
Rate for Payer: United Healthcare Commercial	$141.75

64405 Occipital nerve block (can only be reported once-even if bilateral)

Professional

Both

$332.00

Service Code	CPT 64405
Hospital Charge Code	8799212
Hospital Revenue Code	975
Min. Negotiated Rate	$46.63
Max. Negotiated Rate	$232.40
Rate for Payer: Aetna of IA Medicare	$46.63
Rate for Payer: Amerigroup Medicaid	$48.22
Rate for Payer: Cash Price	$265.60
Rate for Payer: Cash Price	$265.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.96
Rate for Payer: Iowa Total Care Managed Medicaid	$47.56
Rate for Payer: Medical Associates Commercial	$88.60
Rate for Payer: Medical Associates Managed Medicare	$46.63
Rate for Payer: Midlands Choice Commercial	$232.40
Rate for Payer: Oscar Health of IA Commercial	$80.67
Rate for Payer: Partners Health Alliance Commercial	$69.94

64451 INJ AA/STRD Nerves NRVTG SI Joint W/IMG

Professional

Both

$699.00

Service Code	CPT 64451
Hospital Charge Code	8801477
Hospital Revenue Code	975
Min. Negotiated Rate	$74.89
Max. Negotiated Rate	$489.30
Rate for Payer: Aetna of IA Medicare	$74.89
Rate for Payer: Amerigroup Medicaid	$77.44
Rate for Payer: Cash Price	$559.20
Rate for Payer: Cash Price	$559.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$89.87
Rate for Payer: Iowa Total Care Managed Medicaid	$76.39
Rate for Payer: Medical Associates Commercial	$142.29
Rate for Payer: Medical Associates Managed Medicare	$74.89
Rate for Payer: Midlands Choice Commercial	$489.30
Rate for Payer: Oscar Health of IA Commercial	$129.56
Rate for Payer: Partners Health Alliance Commercial	$112.34

64454 Injection genicular nerve branches incl/ imaging when guidance

Professional

Both

$706.00

Service Code	CPT 64454
Hospital Charge Code	8799213
Hospital Revenue Code	975
Min. Negotiated Rate	$75.48
Max. Negotiated Rate	$494.20
Rate for Payer: Aetna of IA Medicare	$75.48
Rate for Payer: Amerigroup Medicaid	$78.05
Rate for Payer: Cash Price	$564.80
Rate for Payer: Cash Price	$564.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$90.58
Rate for Payer: Iowa Total Care Managed Medicaid	$76.99
Rate for Payer: Medical Associates Commercial	$143.41
Rate for Payer: Medical Associates Managed Medicare	$75.48
Rate for Payer: Midlands Choice Commercial	$494.20
Rate for Payer: Oscar Health of IA Commercial	$130.58
Rate for Payer: Partners Health Alliance Commercial	$113.22

64479 INJ Foramen Epidural C/T

Professional

Both

$847.00

Service Code	CPT 64479
Hospital Charge Code	8801475
Hospital Revenue Code	975
Min. Negotiated Rate	$119.68
Max. Negotiated Rate	$592.90
Rate for Payer: Aetna of IA Medicare	$119.68
Rate for Payer: Amerigroup Medicaid	$123.75
Rate for Payer: Cash Price	$677.60
Rate for Payer: Cash Price	$677.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$143.62
Rate for Payer: Iowa Total Care Managed Medicaid	$122.07
Rate for Payer: Medical Associates Commercial	$227.39
Rate for Payer: Medical Associates Managed Medicare	$119.68
Rate for Payer: Midlands Choice Commercial	$592.90
Rate for Payer: Oscar Health of IA Commercial	$207.05
Rate for Payer: Partners Health Alliance Commercial	$179.52

64480 INJ Foramen Epidural Add-On

Professional

Both

$421.00

Service Code	CPT 64480
Hospital Charge Code	8801476
Hospital Revenue Code	975
Min. Negotiated Rate	$55.89
Max. Negotiated Rate	$294.70
Rate for Payer: Aetna of IA Medicare	$55.89
Rate for Payer: Amerigroup Medicaid	$57.79
Rate for Payer: Cash Price	$336.80
Rate for Payer: Cash Price	$336.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$67.07
Rate for Payer: Iowa Total Care Managed Medicaid	$57.01
Rate for Payer: Medical Associates Commercial	$106.19
Rate for Payer: Medical Associates Managed Medicare	$55.89
Rate for Payer: Midlands Choice Commercial	$294.70
Rate for Payer: Oscar Health of IA Commercial	$96.69
Rate for Payer: Partners Health Alliance Commercial	$83.84

64561 PERCUTANEOUS IMPLANT NEUROELECTRODES

Professional

Both

$2,732.00

Service Code	CPT 64561
Hospital Charge Code	8068904
Hospital Revenue Code	975
Min. Negotiated Rate	$275.30
Max. Negotiated Rate	$1,912.40
Rate for Payer: Aetna of IA Medicare	$275.30
Rate for Payer: Amerigroup Medicaid	$284.66
Rate for Payer: Cash Price	$2,185.60
Rate for Payer: Cash Price	$2,185.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$330.36
Rate for Payer: Iowa Total Care Managed Medicaid	$280.81
Rate for Payer: Medical Associates Commercial	$523.07
Rate for Payer: Medical Associates Managed Medicare	$275.30
Rate for Payer: Midlands Choice Commercial	$1,912.40
Rate for Payer: Oscar Health of IA Commercial	$476.27
Rate for Payer: Partners Health Alliance Commercial	$412.95

64581 INCISION FOR IMPLANT NEUROELECTRODES

Professional

Both

$2,232.00

Service Code	CPT 64581
Hospital Charge Code	8068905
Hospital Revenue Code	975
Min. Negotiated Rate	$596.22
Max. Negotiated Rate	$1,562.40
Rate for Payer: Aetna of IA Medicare	$596.22
Rate for Payer: Amerigroup Medicaid	$616.49
Rate for Payer: Cash Price	$1,785.60
Rate for Payer: Cash Price	$1,785.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$715.46
Rate for Payer: Iowa Total Care Managed Medicaid	$608.14
Rate for Payer: Medical Associates Commercial	$1,132.82
Rate for Payer: Medical Associates Managed Medicare	$596.22
Rate for Payer: Midlands Choice Commercial	$1,562.40
Rate for Payer: Oscar Health of IA Commercial	$1,031.46
Rate for Payer: Partners Health Alliance Commercial	$894.33

64590 INSERTION/REPLACEMENT OF NEUROSTIMULATOR GEN OR REC

Professional

Both

$882.00

Service Code	CPT 64590
Hospital Charge Code	8068906
Hospital Revenue Code	975
Min. Negotiated Rate	$267.61
Max. Negotiated Rate	$617.40
Rate for Payer: Aetna of IA Medicare	$267.61
Rate for Payer: Amerigroup Medicaid	$276.71
Rate for Payer: Cash Price	$705.60
Rate for Payer: Cash Price	$705.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$321.13
Rate for Payer: Iowa Total Care Managed Medicaid	$272.96
Rate for Payer: Medical Associates Commercial	$508.46
Rate for Payer: Medical Associates Managed Medicare	$267.61
Rate for Payer: Midlands Choice Commercial	$617.40
Rate for Payer: Oscar Health of IA Commercial	$462.97
Rate for Payer: Partners Health Alliance Commercial	$401.42

Know your out-of-pocket cost for care.

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