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	$304.43
Max. Negotiated Rate	$497.25
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Medical Associates Commercial	$497.25
Rate for Payer: Midlands Choice Commercial	$464.10
Rate for Payer: Partners Health Alliance Commercial	$497.25
Rate for Payer: United Healthcare Commercial	$304.43

54520 ORCHIECTOMY

Professional

Both

$1,099.00

Service Code	CPT 54520
Hospital Charge Code	8300879
Hospital Revenue Code	975
Min. Negotiated Rate	$502.64
Max. Negotiated Rate	$824.25
Rate for Payer: Cash Price	$879.20
Rate for Payer: Cash Price	$879.20
Rate for Payer: Medical Associates Commercial	$824.25
Rate for Payer: Midlands Choice Commercial	$769.30
Rate for Payer: Partners Health Alliance Commercial	$824.25
Rate for Payer: United Healthcare Commercial	$502.64

54700 IncisionDrainage- epididymis testis/scrotum

Professional

Both

$719.00

Service Code	CPT 54700
Hospital Charge Code	8799197
Hospital Revenue Code	975
Min. Negotiated Rate	$329.20
Max. Negotiated Rate	$539.25
Rate for Payer: Cash Price	$575.20
Rate for Payer: Cash Price	$575.20
Rate for Payer: Medical Associates Commercial	$539.25
Rate for Payer: Midlands Choice Commercial	$503.30
Rate for Payer: Partners Health Alliance Commercial	$539.25
Rate for Payer: United Healthcare Commercial	$329.20

55100 Drainage scrotal wall abscess

Professional

Both

$750.00

Service Code	CPT 55100
Hospital Charge Code	8799198
Hospital Revenue Code	975
Min. Negotiated Rate	$340.16
Max. Negotiated Rate	$562.50
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Medical Associates Commercial	$562.50
Rate for Payer: Midlands Choice Commercial	$525.00
Rate for Payer: Partners Health Alliance Commercial	$562.50
Rate for Payer: United Healthcare Commercial	$340.16

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	$684.98
Max. Negotiated Rate	$1,144.50
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Medical Associates Commercial	$1,144.50
Rate for Payer: Midlands Choice Commercial	$1,068.20
Rate for Payer: Partners Health Alliance Commercial	$1,144.50
Rate for Payer: United Healthcare Commercial	$684.98

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	$132.30
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Medical Associates Commercial	$141.75
Rate for Payer: Midlands Choice Commercial	$132.30
Rate for Payer: Partners Health Alliance Commercial	$141.75
Rate for Payer: United Healthcare Commercial	$194.00

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	$277.38
Max. Negotiated Rate	$451.50
Rate for Payer: Cash Price	$481.60
Rate for Payer: Cash Price	$481.60
Rate for Payer: Medical Associates Commercial	$451.50
Rate for Payer: Midlands Choice Commercial	$421.40
Rate for Payer: Partners Health Alliance Commercial	$451.50
Rate for Payer: United Healthcare Commercial	$277.38

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	$137.06
Max. Negotiated Rate	$357.75
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cash Price	$381.60
Rate for Payer: Medical Associates Commercial	$357.75
Rate for Payer: Midlands Choice Commercial	$333.90
Rate for Payer: Partners Health Alliance Commercial	$357.75
Rate for Payer: United Healthcare Commercial	$137.06

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	$58.58
Max. Negotiated Rate	$94.50
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Medical Associates Commercial	$94.50
Rate for Payer: Midlands Choice Commercial	$88.20
Rate for Payer: Partners Health Alliance Commercial	$94.50
Rate for Payer: United Healthcare Commercial	$58.58

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	$299.90
Max. Negotiated Rate	$471.00
Rate for Payer: Cash Price	$502.40
Rate for Payer: Cash Price	$502.40
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: Partners Health Alliance Commercial	$471.00
Rate for Payer: United Healthcare Commercial	$299.90

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	$929.70
Max. Negotiated Rate	$1,671.75
Rate for Payer: Cash Price	$1,783.20
Rate for Payer: Cash Price	$1,783.20
Rate for Payer: Medical Associates Commercial	$1,671.75
Rate for Payer: Midlands Choice Commercial	$1,560.30
Rate for Payer: Partners Health Alliance Commercial	$1,671.75
Rate for Payer: United Healthcare Commercial	$929.70

57250 POSTERIOR COLP RECTOCELE

Professional

Both

$2,242.00

Service Code	CPT 57250
Hospital Charge Code	8378873
Hospital Revenue Code	975
Min. Negotiated Rate	$933.50
Max. Negotiated Rate	$1,681.50
Rate for Payer: Cash Price	$1,793.60
Rate for Payer: Cash Price	$1,793.60
Rate for Payer: Medical Associates Commercial	$1,681.50
Rate for Payer: Midlands Choice Commercial	$1,569.40
Rate for Payer: Partners Health Alliance Commercial	$1,681.50
Rate for Payer: United Healthcare Commercial	$933.50

57260 COMB ANTROPOSTERIER COLP

Professional

Both

$2,761.00

Service Code	CPT 57260
Hospital Charge Code	8378874
Hospital Revenue Code	975
Min. Negotiated Rate	$1,190.11
Max. Negotiated Rate	$2,070.75
Rate for Payer: Cash Price	$2,208.80
Rate for Payer: Cash Price	$2,208.80
Rate for Payer: Medical Associates Commercial	$2,070.75
Rate for Payer: Midlands Choice Commercial	$1,932.70
Rate for Payer: Partners Health Alliance Commercial	$2,070.75
Rate for Payer: United Healthcare Commercial	$1,190.11

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	$1,334.61
Max. Negotiated Rate	$2,269.50
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Medical Associates Commercial	$2,269.50
Rate for Payer: Midlands Choice Commercial	$2,118.20
Rate for Payer: Partners Health Alliance Commercial	$2,269.50
Rate for Payer: United Healthcare Commercial	$1,334.61

57267 VAGINAL INSERT MESH/SLING

Professional

Both

$853.00

Service Code	CPT 57267
Hospital Charge Code	8378870
Hospital Revenue Code	975
Min. Negotiated Rate	$391.66
Max. Negotiated Rate	$639.75
Rate for Payer: Cash Price	$682.40
Rate for Payer: Cash Price	$682.40
Rate for Payer: Medical Associates Commercial	$639.75
Rate for Payer: Midlands Choice Commercial	$597.10
Rate for Payer: Partners Health Alliance Commercial	$639.75
Rate for Payer: United Healthcare Commercial	$391.66

57268 REPAIR ENTEROCELE/VAGINAL

Professional

Both

$1,606.00

Service Code	CPT 57268
Hospital Charge Code	8378876
Hospital Revenue Code	975
Min. Negotiated Rate	$760.66
Max. Negotiated Rate	$1,204.50
Rate for Payer: Cash Price	$1,284.80
Rate for Payer: Cash Price	$1,284.80
Rate for Payer: Medical Associates Commercial	$1,204.50
Rate for Payer: Midlands Choice Commercial	$1,124.20
Rate for Payer: Partners Health Alliance Commercial	$1,204.50
Rate for Payer: United Healthcare Commercial	$760.66

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	$1,056.34
Max. Negotiated Rate	$1,675.50
Rate for Payer: Cash Price	$1,787.20
Rate for Payer: Cash Price	$1,787.20
Rate for Payer: Medical Associates Commercial	$1,675.50
Rate for Payer: Midlands Choice Commercial	$1,563.80
Rate for Payer: Partners Health Alliance Commercial	$1,675.50
Rate for Payer: United Healthcare Commercial	$1,056.34

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	$1,100.85
Max. Negotiated Rate	$1,700.25
Rate for Payer: Cash Price	$1,813.60
Rate for Payer: Cash Price	$1,813.60
Rate for Payer: Medical Associates Commercial	$1,700.25
Rate for Payer: Midlands Choice Commercial	$1,586.90
Rate for Payer: Partners Health Alliance Commercial	$1,700.25
Rate for Payer: United Healthcare Commercial	$1,100.85

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	$1,127.79
Max. Negotiated Rate	$1,787.25
Rate for Payer: Cash Price	$1,906.40
Rate for Payer: Cash Price	$1,906.40
Rate for Payer: Medical Associates Commercial	$1,787.25
Rate for Payer: Midlands Choice Commercial	$1,668.10
Rate for Payer: Partners Health Alliance Commercial	$1,787.25
Rate for Payer: United Healthcare Commercial	$1,127.79

57421 VAGINAL COLPOSCOPY W/BIOPSY

Professional

Both

$523.00

Service Code	CPT 57421
Hospital Charge Code	8378866
Hospital Revenue Code	975
Min. Negotiated Rate	$256.59
Max. Negotiated Rate	$392.25
Rate for Payer: Cash Price	$418.40
Rate for Payer: Cash Price	$418.40
Rate for Payer: Medical Associates Commercial	$392.25
Rate for Payer: Midlands Choice Commercial	$366.10
Rate for Payer: Partners Health Alliance Commercial	$392.25
Rate for Payer: United Healthcare Commercial	$256.59

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	$1,424.03
Max. Negotiated Rate	$2,269.50
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Cash Price	$2,420.80
Rate for Payer: Medical Associates Commercial	$2,269.50
Rate for Payer: Midlands Choice Commercial	$2,118.20
Rate for Payer: Partners Health Alliance Commercial	$2,269.50
Rate for Payer: United Healthcare Commercial	$1,424.03

57425 COLPOPEXY - LAPAROSCOPIC

Professional

Both

$3,223.00

Service Code	CPT 57425
Hospital Charge Code	8378878
Hospital Revenue Code	975
Min. Negotiated Rate	$1,504.98
Max. Negotiated Rate	$2,417.25
Rate for Payer: Cash Price	$2,578.40
Rate for Payer: Cash Price	$2,578.40
Rate for Payer: Medical Associates Commercial	$2,417.25
Rate for Payer: Midlands Choice Commercial	$2,256.10
Rate for Payer: Partners Health Alliance Commercial	$2,417.25
Rate for Payer: United Healthcare Commercial	$1,504.98

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	$519.23
Max. Negotiated Rate	$861.75
Rate for Payer: Cash Price	$919.20
Rate for Payer: Cash Price	$919.20
Rate for Payer: Medical Associates Commercial	$861.75
Rate for Payer: Midlands Choice Commercial	$804.30
Rate for Payer: Partners Health Alliance Commercial	$861.75
Rate for Payer: United Healthcare Commercial	$519.23

57520 CONIZATION OF CERVIX

Professional

Both

$1,021.00

Service Code	CPT 57520
Hospital Charge Code	8378891
Hospital Revenue Code	975
Min. Negotiated Rate	$506.75
Max. Negotiated Rate	$765.75
Rate for Payer: Cash Price	$816.80
Rate for Payer: Cash Price	$816.80
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: Partners Health Alliance Commercial	$765.75
Rate for Payer: United Healthcare Commercial	$506.75

57522 LEEP CERVIX

Professional

Both

$873.00

Service Code	CPT 57522
Hospital Charge Code	8378893
Hospital Revenue Code	975
Min. Negotiated Rate	$435.89
Max. Negotiated Rate	$654.75
Rate for Payer: Cash Price	$698.40
Rate for Payer: Cash Price	$698.40
Rate for Payer: Medical Associates Commercial	$654.75
Rate for Payer: Midlands Choice Commercial	$611.10
Rate for Payer: Partners Health Alliance Commercial	$654.75
Rate for Payer: United Healthcare Commercial	$435.89

Know your out-of-pocket cost for care.

All Charges