Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

11406 Excision benign lesion- trunk arms legs over 4.0 cm

Professional

Both

$1,052.00

Service Code	CPT 11406
Hospital Charge Code	8799087
Hospital Revenue Code	975
Min. Negotiated Rate	$476.08
Max. Negotiated Rate	$789.00
Rate for Payer: Cash Price	$841.60
Rate for Payer: Cash Price	$841.60
Rate for Payer: Medical Associates Commercial	$789.00
Rate for Payer: Midlands Choice Commercial	$736.40
Rate for Payer: Partners Health Alliance Commercial	$789.00
Rate for Payer: United Healthcare Commercial	$476.08

11420 Excision benign lesion; scalp neck hands feet 0.5cm or less

Professional

Both

$420.00

Service Code	CPT 11420
Hospital Charge Code	8799088
Hospital Revenue Code	975
Min. Negotiated Rate	$191.01
Max. Negotiated Rate	$315.00
Rate for Payer: Cash Price	$336.00
Rate for Payer: Cash Price	$336.00
Rate for Payer: Medical Associates Commercial	$315.00
Rate for Payer: Midlands Choice Commercial	$294.00
Rate for Payer: Partners Health Alliance Commercial	$315.00
Rate for Payer: United Healthcare Commercial	$191.01

11421 Excision B9 tumor incl margins scalp neck feet - 0.6-1.0 cm

Professional

Both

$524.00

Service Code	CPT 11421
Hospital Charge Code	8799089
Hospital Revenue Code	975
Min. Negotiated Rate	$240.66
Max. Negotiated Rate	$393.00
Rate for Payer: Cash Price	$419.20
Rate for Payer: Cash Price	$419.20
Rate for Payer: Medical Associates Commercial	$393.00
Rate for Payer: Midlands Choice Commercial	$366.80
Rate for Payer: Partners Health Alliance Commercial	$393.00
Rate for Payer: United Healthcare Commercial	$240.66

11422 Excision benign lesion scalp neck genitalia 1.1-2.0 cm

Professional

Both

$590.00

Service Code	CPT 11422
Hospital Charge Code	8799090
Hospital Revenue Code	975
Min. Negotiated Rate	$270.24
Max. Negotiated Rate	$442.50
Rate for Payer: Cash Price	$472.00
Rate for Payer: Cash Price	$472.00
Rate for Payer: Medical Associates Commercial	$442.50
Rate for Payer: Midlands Choice Commercial	$413.00
Rate for Payer: Partners Health Alliance Commercial	$442.50
Rate for Payer: United Healthcare Commercial	$270.24

11423 Excision benign lesion incl margins 2.1-3.0cm

Professional

Both

$673.00

Service Code	CPT 11423
Hospital Charge Code	8799091
Hospital Revenue Code	975
Min. Negotiated Rate	$307.54
Max. Negotiated Rate	$504.75
Rate for Payer: Cash Price	$538.40
Rate for Payer: Cash Price	$538.40
Rate for Payer: Medical Associates Commercial	$504.75
Rate for Payer: Midlands Choice Commercial	$471.10
Rate for Payer: Partners Health Alliance Commercial	$504.75
Rate for Payer: United Healthcare Commercial	$307.54

11424 Excision benign lesion incl margins 3.1-4.0cm

Professional

Both

$775.00

Service Code	CPT 11424
Hospital Charge Code	8799092
Hospital Revenue Code	975
Min. Negotiated Rate	$354.42
Max. Negotiated Rate	$581.25
Rate for Payer: Cash Price	$620.00
Rate for Payer: Cash Price	$620.00
Rate for Payer: Medical Associates Commercial	$581.25
Rate for Payer: Midlands Choice Commercial	$542.50
Rate for Payer: Partners Health Alliance Commercial	$581.25
Rate for Payer: United Healthcare Commercial	$354.42

11426 Excision benign lesion neck over 4 cm

Professional

Both

$1,115.00

Service Code	CPT 11426
Hospital Charge Code	8799093
Hospital Revenue Code	975
Min. Negotiated Rate	$507.36
Max. Negotiated Rate	$836.25
Rate for Payer: Cash Price	$892.00
Rate for Payer: Cash Price	$892.00
Rate for Payer: Medical Associates Commercial	$836.25
Rate for Payer: Midlands Choice Commercial	$780.50
Rate for Payer: Partners Health Alliance Commercial	$836.25
Rate for Payer: United Healthcare Commercial	$507.36

11443 Excision- B9 lesion: face ears eyelids nose lips 2.1-3.0 cm

Professional

Both

$752.00

Service Code	CPT 11443
Hospital Charge Code	8799094
Hospital Revenue Code	975
Min. Negotiated Rate	$341.46
Max. Negotiated Rate	$564.00
Rate for Payer: Cash Price	$601.60
Rate for Payer: Cash Price	$601.60
Rate for Payer: Medical Associates Commercial	$564.00
Rate for Payer: Midlands Choice Commercial	$526.40
Rate for Payer: Partners Health Alliance Commercial	$564.00
Rate for Payer: United Healthcare Commercial	$341.46

11603 Excision malignant lesion trunk- 2.1- 3.0 cm

Professional

Both

$993.00

Service Code	CPT 11603
Hospital Charge Code	8799095
Hospital Revenue Code	975
Min. Negotiated Rate	$425.20
Max. Negotiated Rate	$744.75
Rate for Payer: Cash Price	$794.40
Rate for Payer: Cash Price	$794.40
Rate for Payer: Medical Associates Commercial	$744.75
Rate for Payer: Midlands Choice Commercial	$695.10
Rate for Payer: Partners Health Alliance Commercial	$744.75
Rate for Payer: United Healthcare Commercial	$425.20

11623 Excision malignant lesion-scalp neck hands feet 2.1-3.0 cm

Professional

Both

$997.00

Service Code	CPT 11623
Hospital Charge Code	8799096
Hospital Revenue Code	975
Min. Negotiated Rate	$452.05
Max. Negotiated Rate	$747.75
Rate for Payer: Cash Price	$797.60
Rate for Payer: Cash Price	$797.60
Rate for Payer: Medical Associates Commercial	$747.75
Rate for Payer: Midlands Choice Commercial	$697.90
Rate for Payer: Partners Health Alliance Commercial	$747.75
Rate for Payer: United Healthcare Commercial	$452.05

11643 Excision malignant lesion-face ears eyelids nose lips- 2.1-3.0 cm

Professional

Both

$1,060.00

Service Code	CPT 11643
Hospital Charge Code	8799097
Hospital Revenue Code	975
Min. Negotiated Rate	$480.59
Max. Negotiated Rate	$795.00
Rate for Payer: Cash Price	$848.00
Rate for Payer: Cash Price	$848.00
Rate for Payer: Medical Associates Commercial	$795.00
Rate for Payer: Midlands Choice Commercial	$742.00
Rate for Payer: Partners Health Alliance Commercial	$795.00
Rate for Payer: United Healthcare Commercial	$480.59

11730 Avulsion of nail plate partial or complete simple; single

Professional

Both

$366.00

Service Code	CPT 11730
Hospital Charge Code	8799098
Hospital Revenue Code	975
Min. Negotiated Rate	$167.58
Max. Negotiated Rate	$274.50
Rate for Payer: Cash Price	$292.80
Rate for Payer: Cash Price	$292.80
Rate for Payer: Medical Associates Commercial	$274.50
Rate for Payer: Midlands Choice Commercial	$256.20
Rate for Payer: Partners Health Alliance Commercial	$274.50
Rate for Payer: United Healthcare Commercial	$167.58

11770 EXC PILONID CYST SIMPLE

Professional

Both

$1,040.00

Service Code	CPT 11770
Hospital Charge Code	8069078
Hospital Revenue Code	975
Min. Negotiated Rate	$465.84
Max. Negotiated Rate	$780.00
Rate for Payer: Cash Price	$832.00
Rate for Payer: Cash Price	$832.00
Rate for Payer: Medical Associates Commercial	$780.00
Rate for Payer: Midlands Choice Commercial	$728.00
Rate for Payer: Partners Health Alliance Commercial	$780.00
Rate for Payer: United Healthcare Commercial	$465.84

11772 Excision of pilonidal cyst/sinus; complicated

Professional

Both

$2,444.00

Service Code	CPT 11772
Hospital Charge Code	8799099
Hospital Revenue Code	975
Min. Negotiated Rate	$1,091.79
Max. Negotiated Rate	$1,833.00
Rate for Payer: Cash Price	$1,955.20
Rate for Payer: Cash Price	$1,955.20
Rate for Payer: Medical Associates Commercial	$1,833.00
Rate for Payer: Midlands Choice Commercial	$1,710.80
Rate for Payer: Partners Health Alliance Commercial	$1,833.00
Rate for Payer: United Healthcare Commercial	$1,091.79

12011 Simple repair/superficial wound of face ears etc 2.5cm or less

Professional

Both

$369.00

Service Code	CPT 12011
Hospital Charge Code	8799100
Hospital Revenue Code	975
Min. Negotiated Rate	$164.86
Max. Negotiated Rate	$276.75
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cash Price	$295.20
Rate for Payer: Medical Associates Commercial	$276.75
Rate for Payer: Midlands Choice Commercial	$258.30
Rate for Payer: Partners Health Alliance Commercial	$276.75
Rate for Payer: United Healthcare Commercial	$164.86

12034 Repair intermediate wounds of scalp trunk extremities- 7.6-12.5 cm

Professional

Both

$1,058.00

Service Code	CPT 12034
Hospital Charge Code	8799101
Hospital Revenue Code	975
Min. Negotiated Rate	$488.45
Max. Negotiated Rate	$793.50
Rate for Payer: Cash Price	$846.40
Rate for Payer: Cash Price	$846.40
Rate for Payer: Medical Associates Commercial	$793.50
Rate for Payer: Midlands Choice Commercial	$740.60
Rate for Payer: Partners Health Alliance Commercial	$793.50
Rate for Payer: United Healthcare Commercial	$488.45

12 HOLE LATERAL FIBULA PLATE SYMMETRIC

Facility

$3,141.00

Service Code	HCPCS C1713
Hospital Charge Code	8986277
Hospital Revenue Code	278
Min. Negotiated Rate	$2,198.70
Max. Negotiated Rate	$2,826.90
Rate for Payer: Aetna of IA Commercial	$2,826.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,826.90
Rate for Payer: Cash Price	$2,512.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,355.75
Rate for Payer: Medical Associates Commercial	$2,355.75
Rate for Payer: Midlands Choice Commercial	$2,198.70
Rate for Payer: United Healthcare Commercial	$2,826.90

12 HOLE LATERAL FIBULA PLATE SYMMETRIC

Facility

$3,141.00

Service Code	HCPCS C1713
Hospital Charge Code	8986277
Hospital Revenue Code	278
Min. Negotiated Rate	$1,413.45
Max. Negotiated Rate	$2,826.90
Rate for Payer: Aetna of IA Commercial	$2,826.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,826.90
Rate for Payer: Aetna of IA Medicare	$1,790.37
Rate for Payer: Amerigroup Medicaid	$1,811.73
Rate for Payer: Amerigroup Medicare	$1,427.58
Rate for Payer: Cash Price	$2,512.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,355.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,413.45
Rate for Payer: Iowa Total Care Managed Medicaid	$1,794.14
Rate for Payer: Medical Associates Commercial	$2,355.75
Rate for Payer: Medical Associates Managed Medicare	$1,413.45
Rate for Payer: Midlands Choice Commercial	$2,198.70
Rate for Payer: Molina Healthcare Managed Medicaid	$1,820.52
Rate for Payer: Partners Health Alliance Commercial	$1,625.47
Rate for Payer: United Healthcare Commercial	$2,826.90
Rate for Payer: United Healthcare Managed Medicare	$1,853.19

13121 Repair complex scalp arms and/or legs 2.6-7.5 cm

Professional

Both

$1,430.00

Service Code	CPT 13121
Hospital Charge Code	8799102
Hospital Revenue Code	975
Min. Negotiated Rate	$650.54
Max. Negotiated Rate	$1,072.50
Rate for Payer: Cash Price	$1,144.00
Rate for Payer: Cash Price	$1,144.00
Rate for Payer: Medical Associates Commercial	$1,072.50
Rate for Payer: Midlands Choice Commercial	$1,001.00
Rate for Payer: Partners Health Alliance Commercial	$1,072.50
Rate for Payer: United Healthcare Commercial	$650.54

13132 Repair complex forehead cheeks neck 2.6 to 7.5 cm

Professional

Both

$1,582.00

Service Code	CPT 13132
Hospital Charge Code	8799103
Hospital Revenue Code	975
Min. Negotiated Rate	$723.20
Max. Negotiated Rate	$1,186.50
Rate for Payer: Cash Price	$1,265.60
Rate for Payer: Cash Price	$1,265.60
Rate for Payer: Medical Associates Commercial	$1,186.50
Rate for Payer: Midlands Choice Commercial	$1,107.40
Rate for Payer: Partners Health Alliance Commercial	$1,186.50
Rate for Payer: United Healthcare Commercial	$723.20

14000 Adjacent tissue transfer/rearrangement; trunk; 10 sq cm or less

Professional

Both

$2,087.00

Service Code	CPT 14000
Hospital Charge Code	8799104
Hospital Revenue Code	975
Min. Negotiated Rate	$942.43
Max. Negotiated Rate	$1,565.25
Rate for Payer: Cash Price	$1,669.60
Rate for Payer: Cash Price	$1,669.60
Rate for Payer: Medical Associates Commercial	$1,565.25
Rate for Payer: Midlands Choice Commercial	$1,460.90
Rate for Payer: Partners Health Alliance Commercial	$1,565.25
Rate for Payer: United Healthcare Commercial	$942.43

14301 Adjacent tissue transfer any area 30.1 sq cm - 60 sq cm

Professional

Both

$3,600.00

Service Code	CPT 14301
Hospital Charge Code	8799106
Hospital Revenue Code	975
Min. Negotiated Rate	$1,632.29
Max. Negotiated Rate	$2,700.00
Rate for Payer: Cash Price	$2,880.00
Rate for Payer: Cash Price	$2,880.00
Rate for Payer: Medical Associates Commercial	$2,700.00
Rate for Payer: Midlands Choice Commercial	$2,520.00
Rate for Payer: Partners Health Alliance Commercial	$2,700.00
Rate for Payer: United Healthcare Commercial	$1,632.29

15275 Application of skin substitute to face feet etc 1st 25 sq cm

Professional

Both

$523.00

Service Code	CPT 15275
Hospital Charge Code	8799107
Hospital Revenue Code	975
Min. Negotiated Rate	$239.17
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	$239.17

15830 PANNICULECTOMY, EXCESSIVE SKIN/TISSUE REMOVAL

Professional

Both

$3,939.00

Service Code	CPT 15830
Hospital Charge Code	8068900
Hospital Revenue Code	975
Min. Negotiated Rate	$1,780.88
Max. Negotiated Rate	$2,954.25
Rate for Payer: Cash Price	$3,151.20
Rate for Payer: Cash Price	$3,151.20
Rate for Payer: Medical Associates Commercial	$2,954.25
Rate for Payer: Midlands Choice Commercial	$2,757.30
Rate for Payer: Partners Health Alliance Commercial	$2,954.25
Rate for Payer: United Healthcare Commercial	$1,780.88

1.6MM COMPRESSION WIRE X 150MM

Facility

$71.00

Service Code	HCPCS C1763
Hospital Charge Code	8748467
Hospital Revenue Code	278
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

Know your out-of-pocket cost for care.

All Charges