Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

49525 HERNIA INGUINAL SLIDING

Professional

Both

$1,932.00

Service Code	CPT 49525
Hospital Charge Code	8069139
Hospital Revenue Code	975
Min. Negotiated Rate	$863.71
Max. Negotiated Rate	$1,449.00
Rate for Payer: Cash Price	$1,545.60
Rate for Payer: Cash Price	$1,545.60
Rate for Payer: Medical Associates Commercial	$1,449.00
Rate for Payer: Midlands Choice Commercial	$1,352.40
Rate for Payer: Partners Health Alliance Commercial	$1,449.00
Rate for Payer: United Healthcare Commercial	$863.71

49550 HERNIA - FEMORAL

Professional

Both

$1,940.00

Service Code	CPT 49550
Hospital Charge Code	8069074
Hospital Revenue Code	975
Min. Negotiated Rate	$867.70
Max. Negotiated Rate	$1,455.00
Rate for Payer: Cash Price	$1,552.00
Rate for Payer: Cash Price	$1,552.00
Rate for Payer: Medical Associates Commercial	$1,455.00
Rate for Payer: Midlands Choice Commercial	$1,358.00
Rate for Payer: Partners Health Alliance Commercial	$1,455.00
Rate for Payer: United Healthcare Commercial	$867.70

49560 HERNIA REPR INIT INCIS/VEN R O

Professional

Both

$2,489.00

Service Code	CPT 49560
Hospital Charge Code	8069088
Hospital Revenue Code	975
Min. Negotiated Rate	$1,742.30
Max. Negotiated Rate	$1,866.75
Rate for Payer: Cash Price	$1,991.20
Rate for Payer: Medical Associates Commercial	$1,866.75
Rate for Payer: Midlands Choice Commercial	$1,742.30
Rate for Payer: Partners Health Alliance Commercial	$1,866.75

49561 HERNIA REPR INIT INC/VENT INCA

Professional

Both

$3,139.00

Service Code	CPT 49561
Hospital Charge Code	8069000
Hospital Revenue Code	975
Min. Negotiated Rate	$2,197.30
Max. Negotiated Rate	$2,354.25
Rate for Payer: Cash Price	$2,511.20
Rate for Payer: Medical Associates Commercial	$2,354.25
Rate for Payer: Midlands Choice Commercial	$2,197.30
Rate for Payer: Partners Health Alliance Commercial	$2,354.25

49565 HERNIA REPR RECUR INC/VENT REDUCIBLE

Professional

Both

$2,592.00

Service Code	CPT 49565
Hospital Charge Code	8069002
Hospital Revenue Code	975
Min. Negotiated Rate	$1,814.40
Max. Negotiated Rate	$1,944.00
Rate for Payer: Cash Price	$2,073.60
Rate for Payer: Medical Associates Commercial	$1,944.00
Rate for Payer: Midlands Choice Commercial	$1,814.40
Rate for Payer: Partners Health Alliance Commercial	$1,944.00

49566 HERNIA REPR REC INC VENT INC O

Professional

Both

$3,167.00

Service Code	CPT 49566
Hospital Charge Code	8069056
Hospital Revenue Code	975
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$2,375.25
Rate for Payer: Cash Price	$2,533.60
Rate for Payer: Medical Associates Commercial	$2,375.25
Rate for Payer: Midlands Choice Commercial	$2,216.90
Rate for Payer: Partners Health Alliance Commercial	$2,375.25

49568 HERNIA REPAIR WITH MESH IMPLANT

Professional

Both

$905.00

Service Code	CPT 49568
Hospital Charge Code	8068964
Hospital Revenue Code	975
Min. Negotiated Rate	$633.50
Max. Negotiated Rate	$678.75
Rate for Payer: Cash Price	$724.00
Rate for Payer: Medical Associates Commercial	$678.75
Rate for Payer: Midlands Choice Commercial	$633.50
Rate for Payer: Partners Health Alliance Commercial	$678.75

49570 HERNIA REP EPIGASTRIC

Professional

Both

$1,403.00

Service Code	CPT 49570
Hospital Charge Code	8069143
Hospital Revenue Code	975
Min. Negotiated Rate	$982.10
Max. Negotiated Rate	$1,052.25
Rate for Payer: Cash Price	$1,122.40
Rate for Payer: Medical Associates Commercial	$1,052.25
Rate for Payer: Midlands Choice Commercial	$982.10
Rate for Payer: Partners Health Alliance Commercial	$1,052.25

49585 HERNIA UMBILICAL > AGE 5

Professional

Both

$1,499.00

Service Code	CPT 49585
Hospital Charge Code	8069162
Hospital Revenue Code	975
Min. Negotiated Rate	$1,049.30
Max. Negotiated Rate	$1,124.25
Rate for Payer: Cash Price	$1,199.20
Rate for Payer: Medical Associates Commercial	$1,124.25
Rate for Payer: Midlands Choice Commercial	$1,049.30
Rate for Payer: Partners Health Alliance Commercial	$1,124.25

49587 HERNIA REPR UMBIL INCARC >5YR

Professional

Both

$1,600.00

Service Code	CPT 49587
Hospital Charge Code	8068963
Hospital Revenue Code	975
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Cash Price	$1,280.00
Rate for Payer: Medical Associates Commercial	$1,200.00
Rate for Payer: Midlands Choice Commercial	$1,120.00
Rate for Payer: Partners Health Alliance Commercial	$1,200.00

49650 HERNIA REPR INGUINAL LAP INIT

Professional

Both

$1,443.00

Service Code	CPT 49650
Hospital Charge Code	8069013
Hospital Revenue Code	975
Min. Negotiated Rate	$646.70
Max. Negotiated Rate	$1,082.25
Rate for Payer: Cash Price	$1,154.40
Rate for Payer: Cash Price	$1,154.40
Rate for Payer: Medical Associates Commercial	$1,082.25
Rate for Payer: Midlands Choice Commercial	$1,010.10
Rate for Payer: Partners Health Alliance Commercial	$1,082.25
Rate for Payer: United Healthcare Commercial	$646.70

49651 HERNIA REPR INGUINAL LAP RECUR

Professional

Both

$1,876.00

Service Code	CPT 49651
Hospital Charge Code	8069057
Hospital Revenue Code	975
Min. Negotiated Rate	$842.42
Max. Negotiated Rate	$1,407.00
Rate for Payer: Cash Price	$1,500.80
Rate for Payer: Cash Price	$1,500.80
Rate for Payer: Medical Associates Commercial	$1,407.00
Rate for Payer: Midlands Choice Commercial	$1,313.20
Rate for Payer: Partners Health Alliance Commercial	$1,407.00
Rate for Payer: United Healthcare Commercial	$842.42

49652 HERNIA REPAIR LAP VENT/ABD

Professional

Both

$2,509.00

Service Code	CPT 49652
Hospital Charge Code	8069066
Hospital Revenue Code	975
Min. Negotiated Rate	$1,756.30
Max. Negotiated Rate	$1,881.75
Rate for Payer: Cash Price	$2,007.20
Rate for Payer: Medical Associates Commercial	$1,881.75
Rate for Payer: Midlands Choice Commercial	$1,756.30
Rate for Payer: Partners Health Alliance Commercial	$1,881.75

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

Professional

Both

$3,159.00

Service Code	CPT 49653
Hospital Charge Code	8799194
Hospital Revenue Code	975
Min. Negotiated Rate	$2,211.30
Max. Negotiated Rate	$2,369.25
Rate for Payer: Cash Price	$2,527.20
Rate for Payer: Medical Associates Commercial	$2,369.25
Rate for Payer: Midlands Choice Commercial	$2,211.30
Rate for Payer: Partners Health Alliance Commercial	$2,369.25

49654 Laparoscopic surgical repair incisional hernia reducible

Professional

Both

$2,853.00

Service Code	CPT 49654
Hospital Charge Code	8799195
Hospital Revenue Code	975
Min. Negotiated Rate	$1,997.10
Max. Negotiated Rate	$2,139.75
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Medical Associates Commercial	$2,139.75
Rate for Payer: Midlands Choice Commercial	$1,997.10
Rate for Payer: Partners Health Alliance Commercial	$2,139.75

4-HOLE CUSTOM PLATE

Facility

$2,178.00

Service Code	HCPCS C1713
Hospital Charge Code	8759892
Hospital Revenue Code	278
Min. Negotiated Rate	$980.10
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	$1,256.27
Rate for Payer: Amerigroup Medicare	$989.90
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	$980.10
Rate for Payer: Iowa Total Care Managed Medicaid	$1,244.07
Rate for Payer: Medical Associates Commercial	$1,633.50
Rate for Payer: Medical Associates Managed Medicare	$980.10
Rate for Payer: Midlands Choice Commercial	$1,524.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.37
Rate for Payer: Partners Health Alliance Commercial	$1,127.12
Rate for Payer: United Healthcare Commercial	$1,960.20
Rate for Payer: United Healthcare Managed Medicare	$1,285.02

4-HOLE CUSTOM PLATE

Facility

$2,178.00

Service Code	HCPCS 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 POSTERIOR MALLEOALAR PLATE

Facility

$2,340.00

Service Code	HCPCS C1713
Hospital Charge Code	8967715
Hospital Revenue Code	278
Min. Negotiated Rate	$1,638.00
Max. Negotiated Rate	$2,106.00
Rate for Payer: Aetna of IA Commercial	$2,106.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,106.00
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,755.00
Rate for Payer: Medical Associates Commercial	$1,755.00
Rate for Payer: Midlands Choice Commercial	$1,638.00
Rate for Payer: United Healthcare Commercial	$2,106.00

4 HOLE POSTERIOR MALLEOALAR PLATE

Facility

$2,340.00

Service Code	HCPCS C1713
Hospital Charge Code	8967715
Hospital Revenue Code	278
Min. Negotiated Rate	$1,053.00
Max. Negotiated Rate	$2,106.00
Rate for Payer: Aetna of IA Commercial	$2,106.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,106.00
Rate for Payer: Aetna of IA Medicare	$1,333.80
Rate for Payer: Amerigroup Medicaid	$1,349.71
Rate for Payer: Amerigroup Medicare	$1,063.53
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,755.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,053.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,336.61
Rate for Payer: Medical Associates Commercial	$1,755.00
Rate for Payer: Medical Associates Managed Medicare	$1,053.00
Rate for Payer: Midlands Choice Commercial	$1,638.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,356.26
Rate for Payer: Partners Health Alliance Commercial	$1,210.95
Rate for Payer: United Healthcare Commercial	$2,106.00
Rate for Payer: United Healthcare Managed Medicare	$1,380.60

51040 CATH SUPERPUBIC

Professional

Both

$974.00

Service Code	CPT 51040
Hospital Charge Code	8068976
Hospital Revenue Code	975
Min. Negotiated Rate	$446.40
Max. Negotiated Rate	$730.50
Rate for Payer: Cash Price	$779.20
Rate for Payer: Cash Price	$779.20
Rate for Payer: Medical Associates Commercial	$730.50
Rate for Payer: Midlands Choice Commercial	$681.80
Rate for Payer: Partners Health Alliance Commercial	$730.50
Rate for Payer: United Healthcare Commercial	$446.40

51705 CYSTOSTOMY TUBE CHANGE SIMPLE

Professional

Both

$302.00

Service Code	CPT 51705
Hospital Charge Code	8069096
Hospital Revenue Code	975
Min. Negotiated Rate	$143.70
Max. Negotiated Rate	$226.50
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Medical Associates Commercial	$226.50
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: Partners Health Alliance Commercial	$226.50
Rate for Payer: United Healthcare Commercial	$143.70

51725 SIMPLE CYSTOMETROGRAM

Professional

Both

$621.00

Service Code	CPT 51725
Hospital Charge Code	8068956
Hospital Revenue Code	975
Min. Negotiated Rate	$320.26
Max. Negotiated Rate	$465.75
Rate for Payer: Cash Price	$496.80
Rate for Payer: Cash Price	$496.80
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: Partners Health Alliance Commercial	$465.75
Rate for Payer: United Healthcare Commercial	$320.26

52000 BLADDER CYSTOURETHROSCOPY

Professional

Both

$546.00

Service Code	CPT 52000
Hospital Charge Code	8378861
Hospital Revenue Code	975
Min. Negotiated Rate	$316.91
Max. Negotiated Rate	$409.50
Rate for Payer: Cash Price	$436.80
Rate for Payer: Cash Price	$436.80
Rate for Payer: Medical Associates Commercial	$409.50
Rate for Payer: Midlands Choice Commercial	$382.20
Rate for Payer: Partners Health Alliance Commercial	$409.50
Rate for Payer: United Healthcare Commercial	$316.91

52260 BLADDER CYSTOUR W/ DILATION OF BLADDER

Professional

Both

$354.00

Service Code	CPT 52260
Hospital Charge Code	8378862
Hospital Revenue Code	975
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$326.03
Rate for Payer: Cash Price	$283.20
Rate for Payer: Cash Price	$283.20
Rate for Payer: Medical Associates Commercial	$265.50
Rate for Payer: Midlands Choice Commercial	$247.80
Rate for Payer: Partners Health Alliance Commercial	$265.50
Rate for Payer: United Healthcare Commercial	$326.03

54001 SLIT PREPUCE DORSAL OR LAT; NOT NEWBORN

Professional

Both

$616.00

Service Code	CPT 54001
Hospital Charge Code	8068957
Hospital Revenue Code	975
Min. Negotiated Rate	$295.17
Max. Negotiated Rate	$462.00
Rate for Payer: Cash Price	$492.80
Rate for Payer: Cash Price	$492.80
Rate for Payer: Medical Associates Commercial	$462.00
Rate for Payer: Midlands Choice Commercial	$431.20
Rate for Payer: Partners Health Alliance Commercial	$462.00
Rate for Payer: United Healthcare Commercial	$295.17

Know your out-of-pocket cost for care.

All Charges