Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

46080 SPHINCTEROTOMY OR

Professional

Both

$828.00

Service Code	CPT 46080
Hospital Charge Code	8069038
Hospital Revenue Code	975
Min. Negotiated Rate	$404.67
Max. Negotiated Rate	$621.00
Rate for Payer: Cash Price	$662.40
Rate for Payer: Cash Price	$662.40
Rate for Payer: Medical Associates Commercial	$621.00
Rate for Payer: Midlands Choice Commercial	$579.60
Rate for Payer: Partners Health Alliance Commercial	$621.00
Rate for Payer: United Healthcare Commercial	$404.67

46083 INCISN THROMBD HEMMRHOID EXTER

Professional

Both

$588.00

Service Code	CPT 46083
Hospital Charge Code	8069043
Hospital Revenue Code	975
Min. Negotiated Rate	$289.36
Max. Negotiated Rate	$441.00
Rate for Payer: Cash Price	$470.40
Rate for Payer: Cash Price	$470.40
Rate for Payer: Medical Associates Commercial	$441.00
Rate for Payer: Midlands Choice Commercial	$411.60
Rate for Payer: Partners Health Alliance Commercial	$441.00
Rate for Payer: United Healthcare Commercial	$289.36

46200 FISSURECTOMY W-W/O SPHINCTRTMY

Professional

Both

$1,488.00

Service Code	CPT 46200
Hospital Charge Code	8069003
Hospital Revenue Code	975
Min. Negotiated Rate	$695.94
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	$695.94

46220 EXCISE ANAL EXT TAG/PAPILLA

Professional

Both

$686.00

Service Code	CPT 46220
Hospital Charge Code	8069070
Hospital Revenue Code	975
Min. Negotiated Rate	$343.36
Max. Negotiated Rate	$514.50
Rate for Payer: Cash Price	$548.80
Rate for Payer: Cash Price	$548.80
Rate for Payer: Medical Associates Commercial	$514.50
Rate for Payer: Midlands Choice Commercial	$480.20
Rate for Payer: Partners Health Alliance Commercial	$514.50
Rate for Payer: United Healthcare Commercial	$343.36

46221 Hemorrhoid ligation

Professional

Both

$900.00

Service Code	CPT 46221
Hospital Charge Code	8799183
Hospital Revenue Code	975
Min. Negotiated Rate	$414.35
Max. Negotiated Rate	$675.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Medical Associates Commercial	$675.00
Rate for Payer: Midlands Choice Commercial	$630.00
Rate for Payer: Partners Health Alliance Commercial	$675.00
Rate for Payer: United Healthcare Commercial	$414.35

46250 REMOVE EXT HEMORRHOID 2 OR MORE COLUMNS/GROUPS

Professional

Both

$1,544.00

Service Code	CPT 46250
Hospital Charge Code	8069023
Hospital Revenue Code	975
Min. Negotiated Rate	$714.11
Max. Negotiated Rate	$1,158.00
Rate for Payer: Cash Price	$1,235.20
Rate for Payer: Cash Price	$1,235.20
Rate for Payer: Medical Associates Commercial	$1,158.00
Rate for Payer: Midlands Choice Commercial	$1,080.80
Rate for Payer: Partners Health Alliance Commercial	$1,158.00
Rate for Payer: United Healthcare Commercial	$714.11

46280 FISTULCTOMY COMPLX W-W/O SETON

Professional

Both

$1,577.00

Service Code	CPT 46280
Hospital Charge Code	8069102
Hospital Revenue Code	975
Min. Negotiated Rate	$722.51
Max. Negotiated Rate	$1,182.75
Rate for Payer: Cash Price	$1,261.60
Rate for Payer: Cash Price	$1,261.60
Rate for Payer: Medical Associates Commercial	$1,182.75
Rate for Payer: Midlands Choice Commercial	$1,103.90
Rate for Payer: Partners Health Alliance Commercial	$1,182.75
Rate for Payer: United Healthcare Commercial	$722.51

46405 IncisionDrainage- superficial perianal abscess

Professional

Both

$1,459.00

Service Code	CPT 46045
Hospital Charge Code	8799067
Hospital Revenue Code	975
Min. Negotiated Rate	$661.94
Max. Negotiated Rate	$1,094.25
Rate for Payer: Cash Price	$1,167.20
Rate for Payer: Cash Price	$1,167.20
Rate for Payer: Medical Associates Commercial	$1,094.25
Rate for Payer: Midlands Choice Commercial	$1,021.30
Rate for Payer: Partners Health Alliance Commercial	$1,094.25
Rate for Payer: United Healthcare Commercial	$661.94

46600 Anoscopy- diagnostic w/o bx

Professional

Both

$297.00

Service Code	CPT 46600
Hospital Charge Code	8799188
Hospital Revenue Code	975
Min. Negotiated Rate	$154.42
Max. Negotiated Rate	$222.75
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: Partners Health Alliance Commercial	$222.75
Rate for Payer: United Healthcare Commercial	$154.42

46910 Destruction of lesion(s)- anus

Professional

Both

$863.00

Service Code	CPT 46910
Hospital Charge Code	8799189
Hospital Revenue Code	975
Min. Negotiated Rate	$388.93
Max. Negotiated Rate	$647.25
Rate for Payer: Cash Price	$690.40
Rate for Payer: Cash Price	$690.40
Rate for Payer: Medical Associates Commercial	$647.25
Rate for Payer: Midlands Choice Commercial	$604.10
Rate for Payer: Partners Health Alliance Commercial	$647.25
Rate for Payer: United Healthcare Commercial	$388.93

46946 Hemorroidectomy internal by ligation; 2 or more colums/groups

Professional

Both

$1,070.00

Service Code	CPT 46946
Hospital Charge Code	8799190
Hospital Revenue Code	975
Min. Negotiated Rate	$572.30
Max. Negotiated Rate	$802.50
Rate for Payer: Cash Price	$856.00
Rate for Payer: Cash Price	$856.00
Rate for Payer: Medical Associates Commercial	$802.50
Rate for Payer: Midlands Choice Commercial	$749.00
Rate for Payer: Partners Health Alliance Commercial	$802.50
Rate for Payer: United Healthcare Commercial	$572.30

47000 NEEDLE BX LIVER PERCUTANEOUS

Professional

Both

$1,015.00

Service Code	CPT 47000
Hospital Charge Code	8069085
Hospital Revenue Code	974
Min. Negotiated Rate	$468.74
Max. Negotiated Rate	$761.25
Rate for Payer: Cash Price	$812.00
Rate for Payer: Cash Price	$812.00
Rate for Payer: Medical Associates Commercial	$761.25
Rate for Payer: Midlands Choice Commercial	$710.50
Rate for Payer: Partners Health Alliance Commercial	$761.25
Rate for Payer: United Healthcare Commercial	$468.74

47100 Biopsy of liver wedge

Professional

Both

$2,858.00

Service Code	CPT 47100
Hospital Charge Code	8799191
Hospital Revenue Code	975
Min. Negotiated Rate	$1,275.58
Max. Negotiated Rate	$2,143.50
Rate for Payer: Cash Price	$2,286.40
Rate for Payer: Cash Price	$2,286.40
Rate for Payer: Medical Associates Commercial	$2,143.50
Rate for Payer: Midlands Choice Commercial	$2,000.60
Rate for Payer: Partners Health Alliance Commercial	$2,143.50
Rate for Payer: United Healthcare Commercial	$1,275.58

47562 CHOLECYSTECTOMY LAPAROSCOPIC

Professional

Both

$2,220.00

Service Code	CPT 47562
Hospital Charge Code	8069033
Hospital Revenue Code	975
Min. Negotiated Rate	$991.54
Max. Negotiated Rate	$1,665.00
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Medical Associates Commercial	$1,665.00
Rate for Payer: Midlands Choice Commercial	$1,554.00
Rate for Payer: Partners Health Alliance Commercial	$1,665.00
Rate for Payer: United Healthcare Commercial	$991.54

47563 CHOLECYSTECTOMY LAP W/CHOLANGI

Professional

Both

$2,411.00

Service Code	CPT 47563
Hospital Charge Code	8068970
Hospital Revenue Code	975
Min. Negotiated Rate	$1,079.25
Max. Negotiated Rate	$1,808.25
Rate for Payer: Cash Price	$1,928.80
Rate for Payer: Cash Price	$1,928.80
Rate for Payer: Medical Associates Commercial	$1,808.25
Rate for Payer: Midlands Choice Commercial	$1,687.70
Rate for Payer: Partners Health Alliance Commercial	$1,808.25
Rate for Payer: United Healthcare Commercial	$1,079.25

47564 LAP CHOLE W/ EXPLOR OF COMMON DUCT

Professional

Both

$3,758.00

Service Code	CPT 47564
Hospital Charge Code	8068967
Hospital Revenue Code	975
Min. Negotiated Rate	$1,678.10
Max. Negotiated Rate	$2,818.50
Rate for Payer: Cash Price	$3,006.40
Rate for Payer: Cash Price	$3,006.40
Rate for Payer: Medical Associates Commercial	$2,818.50
Rate for Payer: Midlands Choice Commercial	$2,630.60
Rate for Payer: Partners Health Alliance Commercial	$2,818.50
Rate for Payer: United Healthcare Commercial	$1,678.10

47600 CHOLECYSTECTOMY

Professional

Both

$3,604.00

Service Code	CPT 47600
Hospital Charge Code	8069179
Hospital Revenue Code	975
Min. Negotiated Rate	$1,611.15
Max. Negotiated Rate	$2,703.00
Rate for Payer: Cash Price	$2,883.20
Rate for Payer: Cash Price	$2,883.20
Rate for Payer: Medical Associates Commercial	$2,703.00
Rate for Payer: Midlands Choice Commercial	$2,522.80
Rate for Payer: Partners Health Alliance Commercial	$2,703.00
Rate for Payer: United Healthcare Commercial	$1,611.15

47605 Cholecystectomy; with cholangiography

Professional

Both

$3,802.00

Service Code	CPT 47605
Hospital Charge Code	8799192
Hospital Revenue Code	975
Min. Negotiated Rate	$1,694.64
Max. Negotiated Rate	$2,851.50
Rate for Payer: Cash Price	$3,041.60
Rate for Payer: Cash Price	$3,041.60
Rate for Payer: Medical Associates Commercial	$2,851.50
Rate for Payer: Midlands Choice Commercial	$2,661.40
Rate for Payer: Partners Health Alliance Commercial	$2,851.50
Rate for Payer: United Healthcare Commercial	$1,694.64

49000 LAPAROTOMY

Professional

Both

$2,600.00

Service Code	CPT 49000
Hospital Charge Code	8069048
Hospital Revenue Code	975
Min. Negotiated Rate	$1,160.53
Max. Negotiated Rate	$1,950.00
Rate for Payer: Cash Price	$2,080.00
Rate for Payer: Cash Price	$2,080.00
Rate for Payer: Medical Associates Commercial	$1,950.00
Rate for Payer: Midlands Choice Commercial	$1,820.00
Rate for Payer: Partners Health Alliance Commercial	$1,950.00
Rate for Payer: United Healthcare Commercial	$1,160.53

49320 LAPAROSCOPY DIAGNOSTIC

Professional

Both

$1,098.00

Service Code	CPT 49320
Hospital Charge Code	8378859
Hospital Revenue Code	975
Min. Negotiated Rate	$495.46
Max. Negotiated Rate	$823.50
Rate for Payer: Cash Price	$878.40
Rate for Payer: Cash Price	$878.40
Rate for Payer: Medical Associates Commercial	$823.50
Rate for Payer: Midlands Choice Commercial	$768.60
Rate for Payer: Partners Health Alliance Commercial	$823.50
Rate for Payer: United Healthcare Commercial	$495.46

49505 HERNIA REPR INIT INGUINAL>5YR

Professional

Both

$1,754.00

Service Code	CPT 49505
Hospital Charge Code	8069140
Hospital Revenue Code	975
Min. Negotiated Rate	$784.53
Max. Negotiated Rate	$1,315.50
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Medical Associates Commercial	$1,315.50
Rate for Payer: Midlands Choice Commercial	$1,227.80
Rate for Payer: Partners Health Alliance Commercial	$1,315.50
Rate for Payer: United Healthcare Commercial	$784.53

49507 Repair initial inguinal hernia age 5+ incarcerated/strangulated

Professional

Both

$1,979.00

Service Code	CPT 49507
Hospital Charge Code	8799193
Hospital Revenue Code	975
Min. Negotiated Rate	$882.30
Max. Negotiated Rate	$1,484.25
Rate for Payer: Cash Price	$1,583.20
Rate for Payer: Cash Price	$1,583.20
Rate for Payer: Medical Associates Commercial	$1,484.25
Rate for Payer: Midlands Choice Commercial	$1,385.30
Rate for Payer: Partners Health Alliance Commercial	$1,484.25
Rate for Payer: United Healthcare Commercial	$882.30

49520 HERNIA REP RECUR INGNL REDC ANY AGE

Professional

Both

$2,131.00

Service Code	CPT 49520
Hospital Charge Code	8069154
Hospital Revenue Code	975
Min. Negotiated Rate	$951.22
Max. Negotiated Rate	$1,598.25
Rate for Payer: Cash Price	$1,704.80
Rate for Payer: Cash Price	$1,704.80
Rate for Payer: Medical Associates Commercial	$1,598.25
Rate for Payer: Midlands Choice Commercial	$1,491.70
Rate for Payer: Partners Health Alliance Commercial	$1,598.25
Rate for Payer: United Healthcare Commercial	$951.22

49521 HERNIA REPR INIT HERNIA ANY AGE

Professional

Both

$2,417.00

Service Code	CPT 49521
Hospital Charge Code	8069069
Hospital Revenue Code	975
Min. Negotiated Rate	$1,079.31
Max. Negotiated Rate	$1,812.75
Rate for Payer: Cash Price	$1,933.60
Rate for Payer: Cash Price	$1,933.60
Rate for Payer: Medical Associates Commercial	$1,812.75
Rate for Payer: Midlands Choice Commercial	$1,691.90
Rate for Payer: Partners Health Alliance Commercial	$1,812.75
Rate for Payer: United Healthcare Commercial	$1,079.31

Know your out-of-pocket cost for care.

All Charges