Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

54161 CIRCUMCISION OR

Professional

Both

$663.00

Service Code	CPT 54161
Hospital Charge Code	8068980
Hospital Revenue Code	975
Min. Negotiated Rate	$190.56
Max. Negotiated Rate	$497.25
Rate for Payer: Amerigroup Medicaid	$192.42
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Iowa Total Care Managed Medicaid	$190.56
Rate for Payer: Medical Associates Commercial	$497.25
Rate for Payer: Midlands Choice Commercial	$464.10
Rate for Payer: Molina Healthcare Managed Medicaid	$191.49
Rate for Payer: Partners Health Alliance Commercial	$497.25
Rate for Payer: United Healthcare Commercial	$304.43
Rate for Payer: Wellmark IA HMO WHPI	$372.40
Rate for Payer: Wellmark IA PPO	$438.10

54520 ORCHIECTOMY

Professional

Both

$1,099.00

Service Code	CPT 54520
Hospital Charge Code	8300879
Hospital Revenue Code	975
Min. Negotiated Rate	$344.12
Max. Negotiated Rate	$824.25
Rate for Payer: Amerigroup Medicaid	$347.49
Rate for Payer: Cash Price	$879.20
Rate for Payer: Cash Price	$879.20
Rate for Payer: Iowa Total Care Managed Medicaid	$344.12
Rate for Payer: Medical Associates Commercial	$824.25
Rate for Payer: Midlands Choice Commercial	$769.30
Rate for Payer: Molina Healthcare Managed Medicaid	$345.80
Rate for Payer: Partners Health Alliance Commercial	$824.25
Rate for Payer: United Healthcare Commercial	$502.64
Rate for Payer: Wellmark IA HMO WHPI	$622.10
Rate for Payer: Wellmark IA PPO	$731.90

54700 IncisionDrainage- epididymis testis/scrotum

Professional

Both

$719.00

Service Code	CPT 54700
Hospital Charge Code	8799197
Hospital Revenue Code	975
Min. Negotiated Rate	$272.22
Max. Negotiated Rate	$539.25
Rate for Payer: Amerigroup Medicaid	$274.89
Rate for Payer: Cash Price	$575.20
Rate for Payer: Cash Price	$575.20
Rate for Payer: Iowa Total Care Managed Medicaid	$272.22
Rate for Payer: Medical Associates Commercial	$539.25
Rate for Payer: Midlands Choice Commercial	$503.30
Rate for Payer: Molina Healthcare Managed Medicaid	$273.55
Rate for Payer: Partners Health Alliance Commercial	$539.25
Rate for Payer: United Healthcare Commercial	$329.20
Rate for Payer: Wellmark IA HMO WHPI	$403.20
Rate for Payer: Wellmark IA PPO	$474.30

55100 Drainage scrotal wall abscess

Professional

Both

$750.00

Service Code	CPT 55100
Hospital Charge Code	8799198
Hospital Revenue Code	975
Min. Negotiated Rate	$236.16
Max. Negotiated Rate	$562.50
Rate for Payer: Amerigroup Medicaid	$238.48
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Iowa Total Care Managed Medicaid	$236.16
Rate for Payer: Medical Associates Commercial	$562.50
Rate for Payer: Midlands Choice Commercial	$525.00
Rate for Payer: Molina Healthcare Managed Medicaid	$237.32
Rate for Payer: Partners Health Alliance Commercial	$562.50
Rate for Payer: United Healthcare Commercial	$340.16
Rate for Payer: Wellmark IA HMO WHPI	$439.00
Rate for Payer: Wellmark IA PPO	$516.50

55520 EXCISE LESION OF SPERMATIC CORD

Professional

Both

$1,526.00

Service Code	CPT 55520
Hospital Charge Code	8069128
Hospital Revenue Code	975
Min. Negotiated Rate	$344.86
Max. Negotiated Rate	$1,144.50
Rate for Payer: Amerigroup Medicaid	$348.24
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Iowa Total Care Managed Medicaid	$344.86
Rate for Payer: Medical Associates Commercial	$1,144.50
Rate for Payer: Midlands Choice Commercial	$1,068.20
Rate for Payer: Molina Healthcare Managed Medicaid	$346.55
Rate for Payer: Partners Health Alliance Commercial	$1,144.50
Rate for Payer: United Healthcare Commercial	$684.98
Rate for Payer: Wellmark IA HMO WHPI	$873.10
Rate for Payer: Wellmark IA PPO	$1,027.10

56405 Incision and drainage of vulva or perineal abscess

Professional

Both

$189.00

Service Code	CPT 56405
Hospital Charge Code	8799223
Hospital Revenue Code	975
Min. Negotiated Rate	$103.31
Max. Negotiated Rate	$328.60
Rate for Payer: Amerigroup Medicaid	$104.32
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Iowa Total Care Managed Medicaid	$103.31
Rate for Payer: Medical Associates Commercial	$141.75
Rate for Payer: Midlands Choice Commercial	$132.30
Rate for Payer: Molina Healthcare Managed Medicaid	$103.81
Rate for Payer: Partners Health Alliance Commercial	$141.75
Rate for Payer: United Healthcare Commercial	$194.00
Rate for Payer: Wellmark IA HMO WHPI	$279.30
Rate for Payer: Wellmark IA PPO	$328.60

56440 Marsupialization of Bartholin's gland cyst

Professional

Both

$602.00

Service Code	CPT 56440
Hospital Charge Code	8799224
Hospital Revenue Code	975
Min. Negotiated Rate	$208.46
Max. Negotiated Rate	$451.50
Rate for Payer: Amerigroup Medicaid	$210.50
Rate for Payer: Cash Price	$481.60
Rate for Payer: Cash Price	$481.60
Rate for Payer: Iowa Total Care Managed Medicaid	$208.46
Rate for Payer: Medical Associates Commercial	$451.50
Rate for Payer: Midlands Choice Commercial	$421.40
Rate for Payer: Molina Healthcare Managed Medicaid	$209.48
Rate for Payer: Partners Health Alliance Commercial	$451.50
Rate for Payer: United Healthcare Commercial	$277.38
Rate for Payer: Wellmark IA HMO WHPI	$345.30
Rate for Payer: Wellmark IA PPO	$406.30

56605 BX OF VULVA OR PERINEUM FIRST

Professional

Both

$477.00

Service Code	CPT 56605
Hospital Charge Code	8068998
Hospital Revenue Code	975
Min. Negotiated Rate	$80.84
Max. Negotiated Rate	$357.75
Rate for Payer: Amerigroup Medicaid	$81.63
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cash Price	$381.60
Rate for Payer: Iowa Total Care Managed Medicaid	$80.84
Rate for Payer: Medical Associates Commercial	$357.75
Rate for Payer: Midlands Choice Commercial	$333.90
Rate for Payer: Molina Healthcare Managed Medicaid	$81.23
Rate for Payer: Partners Health Alliance Commercial	$357.75
Rate for Payer: United Healthcare Commercial	$137.06
Rate for Payer: Wellmark IA HMO WHPI	$183.00
Rate for Payer: Wellmark IA PPO	$215.30

56606 BX OF VULVA OR PERINEUM EA ADDTL

Professional

Both

$126.00

Service Code	CPT 56606
Hospital Charge Code	8378865
Hospital Revenue Code	975
Min. Negotiated Rate	$50.48
Max. Negotiated Rate	$94.50
Rate for Payer: Amerigroup Medicaid	$50.97
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Iowa Total Care Managed Medicaid	$50.48
Rate for Payer: Medical Associates Commercial	$94.50
Rate for Payer: Midlands Choice Commercial	$88.20
Rate for Payer: Molina Healthcare Managed Medicaid	$50.73
Rate for Payer: Partners Health Alliance Commercial	$94.50
Rate for Payer: United Healthcare Commercial	$58.58
Rate for Payer: Wellmark IA HMO WHPI	$71.70
Rate for Payer: Wellmark IA PPO	$84.40

56700 Partial hymenectomy or revision of hymenal ring

Professional

Both

$628.00

Service Code	CPT 56700
Hospital Charge Code	8799199
Hospital Revenue Code	975
Min. Negotiated Rate	$174.74
Max. Negotiated Rate	$471.00
Rate for Payer: Amerigroup Medicaid	$176.45
Rate for Payer: Cash Price	$502.40
Rate for Payer: Cash Price	$502.40
Rate for Payer: Iowa Total Care Managed Medicaid	$174.74
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: Molina Healthcare Managed Medicaid	$175.59
Rate for Payer: Partners Health Alliance Commercial	$471.00
Rate for Payer: United Healthcare Commercial	$299.90
Rate for Payer: Wellmark IA HMO WHPI	$386.80
Rate for Payer: Wellmark IA PPO	$455.10

57240 ANTERIOR COLPORRAHAPHY REP CYSTOCELE

Professional

Both

$2,229.00

Service Code	CPT 57240
Hospital Charge Code	8378872
Hospital Revenue Code	975
Min. Negotiated Rate	$413.45
Max. Negotiated Rate	$1,671.75
Rate for Payer: Amerigroup Medicaid	$417.50
Rate for Payer: Cash Price	$1,783.20
Rate for Payer: Cash Price	$1,783.20
Rate for Payer: Iowa Total Care Managed Medicaid	$413.45
Rate for Payer: Medical Associates Commercial	$1,671.75
Rate for Payer: Midlands Choice Commercial	$1,560.30
Rate for Payer: Molina Healthcare Managed Medicaid	$415.47
Rate for Payer: Partners Health Alliance Commercial	$1,671.75
Rate for Payer: United Healthcare Commercial	$929.70
Rate for Payer: Wellmark IA HMO WHPI	$1,164.30
Rate for Payer: Wellmark IA PPO	$1,369.70

57250 POSTERIOR COLP RECTOCELE

Professional

Both

$2,242.00

Service Code	CPT 57250
Hospital Charge Code	8378873
Hospital Revenue Code	975
Min. Negotiated Rate	$374.32
Max. Negotiated Rate	$1,681.50
Rate for Payer: Amerigroup Medicaid	$377.99
Rate for Payer: Cash Price	$1,793.60
Rate for Payer: Cash Price	$1,793.60
Rate for Payer: Iowa Total Care Managed Medicaid	$374.32
Rate for Payer: Medical Associates Commercial	$1,681.50
Rate for Payer: Midlands Choice Commercial	$1,569.40
Rate for Payer: Molina Healthcare Managed Medicaid	$376.15
Rate for Payer: Partners Health Alliance Commercial	$1,681.50
Rate for Payer: United Healthcare Commercial	$933.50
Rate for Payer: Wellmark IA HMO WHPI	$1,169.30
Rate for Payer: Wellmark IA PPO	$1,375.70

57260 COMB ANTROPOSTERIER COLP

Professional

Both

$2,761.00

Service Code	CPT 57260
Hospital Charge Code	8378874
Hospital Revenue Code	975
Min. Negotiated Rate	$540.54
Max. Negotiated Rate	$2,070.75
Rate for Payer: Amerigroup Medicaid	$545.84
Rate for Payer: Cash Price	$2,208.80
Rate for Payer: Cash Price	$2,208.80
Rate for Payer: Iowa Total Care Managed Medicaid	$540.54
Rate for Payer: Medical Associates Commercial	$2,070.75
Rate for Payer: Midlands Choice Commercial	$1,932.70
Rate for Payer: Molina Healthcare Managed Medicaid	$543.19
Rate for Payer: Partners Health Alliance Commercial	$2,070.75
Rate for Payer: United Healthcare Commercial	$1,190.11
Rate for Payer: Wellmark IA HMO WHPI	$1,476.30
Rate for Payer: Wellmark IA PPO	$1,736.80

57265 ANTER/POSTER COLP-ENTERCE

Professional

Both

$3,026.00

Service Code	CPT 57265
Hospital Charge Code	8378875
Hospital Revenue Code	975
Min. Negotiated Rate	$697.69
Max. Negotiated Rate	$2,269.50
Rate for Payer: Amerigroup Medicaid	$704.53
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Iowa Total Care Managed Medicaid	$697.69
Rate for Payer: Medical Associates Commercial	$2,269.50
Rate for Payer: Midlands Choice Commercial	$2,118.20
Rate for Payer: Molina Healthcare Managed Medicaid	$701.11
Rate for Payer: Partners Health Alliance Commercial	$2,269.50
Rate for Payer: United Healthcare Commercial	$1,334.61
Rate for Payer: Wellmark IA HMO WHPI	$1,650.50
Rate for Payer: Wellmark IA PPO	$1,941.80

57267 VAGINAL INSERT MESH/SLING

Professional

Both

$853.00

Service Code	CPT 57267
Hospital Charge Code	8378870
Hospital Revenue Code	975
Min. Negotiated Rate	$268.86
Max. Negotiated Rate	$639.75
Rate for Payer: Amerigroup Medicaid	$271.50
Rate for Payer: Cash Price	$682.40
Rate for Payer: Cash Price	$682.40
Rate for Payer: Iowa Total Care Managed Medicaid	$268.86
Rate for Payer: Medical Associates Commercial	$639.75
Rate for Payer: Midlands Choice Commercial	$597.10
Rate for Payer: Molina Healthcare Managed Medicaid	$270.18
Rate for Payer: Partners Health Alliance Commercial	$639.75
Rate for Payer: United Healthcare Commercial	$391.66
Rate for Payer: Wellmark IA HMO WHPI	$469.20
Rate for Payer: Wellmark IA PPO	$552.00

57268 REPAIR ENTEROCELE/VAGINAL

Professional

Both

$1,606.00

Service Code	CPT 57268
Hospital Charge Code	8378876
Hospital Revenue Code	975
Min. Negotiated Rate	$445.25
Max. Negotiated Rate	$1,204.50
Rate for Payer: Amerigroup Medicaid	$449.62
Rate for Payer: Cash Price	$1,284.80
Rate for Payer: Cash Price	$1,284.80
Rate for Payer: Iowa Total Care Managed Medicaid	$445.25
Rate for Payer: Medical Associates Commercial	$1,204.50
Rate for Payer: Midlands Choice Commercial	$1,124.20
Rate for Payer: Molina Healthcare Managed Medicaid	$447.43
Rate for Payer: Partners Health Alliance Commercial	$1,204.50
Rate for Payer: United Healthcare Commercial	$760.66
Rate for Payer: Wellmark IA HMO WHPI	$964.30
Rate for Payer: Wellmark IA PPO	$1,134.40

57285 PARAVAGINAL DEFECT REPAIR - VAGINAL

Professional

Both

$2,234.00

Service Code	CPT 57285
Hospital Charge Code	8378867
Hospital Revenue Code	975
Min. Negotiated Rate	$502.91
Max. Negotiated Rate	$1,675.50
Rate for Payer: Amerigroup Medicaid	$507.84
Rate for Payer: Cash Price	$1,787.20
Rate for Payer: Cash Price	$1,787.20
Rate for Payer: Iowa Total Care Managed Medicaid	$502.91
Rate for Payer: Medical Associates Commercial	$1,675.50
Rate for Payer: Midlands Choice Commercial	$1,563.80
Rate for Payer: Molina Healthcare Managed Medicaid	$505.38
Rate for Payer: Partners Health Alliance Commercial	$1,675.50
Rate for Payer: United Healthcare Commercial	$1,056.34
Rate for Payer: Wellmark IA HMO WHPI	$1,312.70
Rate for Payer: Wellmark IA PPO	$1,544.40

57287 VAGINAL REMOVAL/REVISION OF SLING

Professional

Both

$2,267.00

Service Code	CPT 57287
Hospital Charge Code	8378869
Hospital Revenue Code	975
Min. Negotiated Rate	$644.67
Max. Negotiated Rate	$1,700.25
Rate for Payer: Amerigroup Medicaid	$650.99
Rate for Payer: Cash Price	$1,813.60
Rate for Payer: Cash Price	$1,813.60
Rate for Payer: Iowa Total Care Managed Medicaid	$644.67
Rate for Payer: Medical Associates Commercial	$1,700.25
Rate for Payer: Midlands Choice Commercial	$1,586.90
Rate for Payer: Molina Healthcare Managed Medicaid	$647.83
Rate for Payer: Partners Health Alliance Commercial	$1,700.25
Rate for Payer: United Healthcare Commercial	$1,100.85
Rate for Payer: Wellmark IA HMO WHPI	$1,409.60
Rate for Payer: Wellmark IA PPO	$1,658.30

57288 VAGINAL SLING FOR STRESS INCONTINENCE

Professional

Both

$2,383.00

Service Code	CPT 57288
Hospital Charge Code	8378871
Hospital Revenue Code	975
Min. Negotiated Rate	$783.43
Max. Negotiated Rate	$1,787.25
Rate for Payer: Amerigroup Medicaid	$791.11
Rate for Payer: Cash Price	$1,906.40
Rate for Payer: Cash Price	$1,906.40
Rate for Payer: Iowa Total Care Managed Medicaid	$783.43
Rate for Payer: Medical Associates Commercial	$1,787.25
Rate for Payer: Midlands Choice Commercial	$1,668.10
Rate for Payer: Molina Healthcare Managed Medicaid	$787.27
Rate for Payer: Partners Health Alliance Commercial	$1,787.25
Rate for Payer: United Healthcare Commercial	$1,127.79
Rate for Payer: Wellmark IA HMO WHPI	$1,410.20
Rate for Payer: Wellmark IA PPO	$1,659.10

57421 VAGINAL COLPOSCOPY W/BIOPSY

Professional

Both

$523.00

Service Code	CPT 57421
Hospital Charge Code	8378866
Hospital Revenue Code	975
Min. Negotiated Rate	$95.69
Max. Negotiated Rate	$398.10
Rate for Payer: Amerigroup Medicaid	$96.62
Rate for Payer: Cash Price	$418.40
Rate for Payer: Cash Price	$418.40
Rate for Payer: Iowa Total Care Managed Medicaid	$95.69
Rate for Payer: Medical Associates Commercial	$392.25
Rate for Payer: Midlands Choice Commercial	$366.10
Rate for Payer: Molina Healthcare Managed Medicaid	$96.16
Rate for Payer: Partners Health Alliance Commercial	$392.25
Rate for Payer: United Healthcare Commercial	$256.59
Rate for Payer: Wellmark IA HMO WHPI	$338.40
Rate for Payer: Wellmark IA PPO	$398.10

57423 PARAVAGINAL DEFECT REPAIR - LAPARORS

Professional

Both

$3,026.00

Service Code	CPT 57423
Hospital Charge Code	8378868
Hospital Revenue Code	975
Min. Negotiated Rate	$695.59
Max. Negotiated Rate	$2,269.50
Rate for Payer: Amerigroup Medicaid	$702.41
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Iowa Total Care Managed Medicaid	$695.59
Rate for Payer: Medical Associates Commercial	$2,269.50
Rate for Payer: Midlands Choice Commercial	$2,118.20
Rate for Payer: Molina Healthcare Managed Medicaid	$699.00
Rate for Payer: Partners Health Alliance Commercial	$2,269.50
Rate for Payer: United Healthcare Commercial	$1,424.03
Rate for Payer: Wellmark IA HMO WHPI	$1,756.80
Rate for Payer: Wellmark IA PPO	$2,066.80

57425 COLPOPEXY - LAPAROSCOPIC

Professional

Both

$3,223.00

Service Code	CPT 57425
Hospital Charge Code	8378878
Hospital Revenue Code	975
Min. Negotiated Rate	$832.26
Max. Negotiated Rate	$2,417.25
Rate for Payer: Amerigroup Medicaid	$840.42
Rate for Payer: Cash Price	$2,578.40
Rate for Payer: Cash Price	$2,578.40
Rate for Payer: Iowa Total Care Managed Medicaid	$832.26
Rate for Payer: Medical Associates Commercial	$2,417.25
Rate for Payer: Midlands Choice Commercial	$2,256.10
Rate for Payer: Molina Healthcare Managed Medicaid	$836.34
Rate for Payer: Partners Health Alliance Commercial	$2,417.25
Rate for Payer: United Healthcare Commercial	$1,504.98
Rate for Payer: Wellmark IA HMO WHPI	$1,840.50
Rate for Payer: Wellmark IA PPO	$2,165.20

57461 Colposcopy of cervix w/loop electrode conization of cervix

Professional

Both

$1,149.00

Service Code	CPT 57461
Hospital Charge Code	8799200
Hospital Revenue Code	975
Min. Negotiated Rate	$291.52
Max. Negotiated Rate	$861.75
Rate for Payer: Amerigroup Medicaid	$294.37
Rate for Payer: Cash Price	$919.20
Rate for Payer: Cash Price	$919.20
Rate for Payer: Iowa Total Care Managed Medicaid	$291.52
Rate for Payer: Medical Associates Commercial	$861.75
Rate for Payer: Midlands Choice Commercial	$804.30
Rate for Payer: Molina Healthcare Managed Medicaid	$292.94
Rate for Payer: Partners Health Alliance Commercial	$861.75
Rate for Payer: United Healthcare Commercial	$519.23
Rate for Payer: Wellmark IA HMO WHPI	$662.30
Rate for Payer: Wellmark IA PPO	$779.20

57520 CONIZATION OF CERVIX

Professional

Both

$1,021.00

Service Code	CPT 57520
Hospital Charge Code	8378891
Hospital Revenue Code	975
Min. Negotiated Rate	$276.47
Max. Negotiated Rate	$793.30
Rate for Payer: Amerigroup Medicaid	$279.18
Rate for Payer: Cash Price	$816.80
Rate for Payer: Cash Price	$816.80
Rate for Payer: Iowa Total Care Managed Medicaid	$276.47
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: Molina Healthcare Managed Medicaid	$277.83
Rate for Payer: Partners Health Alliance Commercial	$765.75
Rate for Payer: United Healthcare Commercial	$506.75
Rate for Payer: Wellmark IA HMO WHPI	$674.30
Rate for Payer: Wellmark IA PPO	$793.30

57522 LEEP CERVIX

Professional

Both

$873.00

Service Code	CPT 57522
Hospital Charge Code	8378893
Hospital Revenue Code	975
Min. Negotiated Rate	$245.39
Max. Negotiated Rate	$680.10
Rate for Payer: Amerigroup Medicaid	$247.80
Rate for Payer: Cash Price	$698.40
Rate for Payer: Cash Price	$698.40
Rate for Payer: Iowa Total Care Managed Medicaid	$245.39
Rate for Payer: Medical Associates Commercial	$654.75
Rate for Payer: Midlands Choice Commercial	$611.10
Rate for Payer: Molina Healthcare Managed Medicaid	$246.59
Rate for Payer: Partners Health Alliance Commercial	$654.75
Rate for Payer: United Healthcare Commercial	$435.89
Rate for Payer: Wellmark IA HMO WHPI	$578.10
Rate for Payer: Wellmark IA PPO	$680.10

Know your out-of-pocket cost for care.

All Charges