Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

57550 EXCISION OF CERVICAL/VAGINAL APP

Professional

Both

$1,344.00

Service Code	CPT 57550
Hospital Charge Code	8378892
Hospital Revenue Code	975
Min. Negotiated Rate	$644.59
Max. Negotiated Rate	$1,008.00
Rate for Payer: Cash Price	$1,075.20
Rate for Payer: Cash Price	$1,075.20
Rate for Payer: Medical Associates Commercial	$1,008.00
Rate for Payer: Midlands Choice Commercial	$940.80
Rate for Payer: Partners Health Alliance Commercial	$1,008.00
Rate for Payer: United Healthcare Commercial	$644.59

58100 ENDOMETRIAL BX W/O CERVICAL DILATION

Professional

Both

$362.00

Service Code	CPT 58100
Hospital Charge Code	8378877
Hospital Revenue Code	975
Min. Negotiated Rate	$147.84
Max. Negotiated Rate	$271.50
Rate for Payer: Cash Price	$289.60
Rate for Payer: Cash Price	$289.60
Rate for Payer: Medical Associates Commercial	$271.50
Rate for Payer: Midlands Choice Commercial	$253.40
Rate for Payer: Partners Health Alliance Commercial	$271.50
Rate for Payer: United Healthcare Commercial	$147.84

58120 DC DIAGNOSTIC OR TEHERAP NOT OB

Professional

Both

$856.00

Service Code	CPT 58120
Hospital Charge Code	8069166
Hospital Revenue Code	975
Min. Negotiated Rate	$426.83
Max. Negotiated Rate	$642.00
Rate for Payer: Cash Price	$684.80
Rate for Payer: Cash Price	$684.80
Rate for Payer: Medical Associates Commercial	$642.00
Rate for Payer: Midlands Choice Commercial	$599.20
Rate for Payer: Partners Health Alliance Commercial	$642.00
Rate for Payer: United Healthcare Commercial	$426.83

58150 TOTAL ABDOMINAL HYSTERECTOMY

Professional

Both

$3,384.00

Service Code	CPT 58150
Hospital Charge Code	8378894
Hospital Revenue Code	975
Min. Negotiated Rate	$1,548.45
Max. Negotiated Rate	$2,538.00
Rate for Payer: Cash Price	$2,707.20
Rate for Payer: Cash Price	$2,707.20
Rate for Payer: Medical Associates Commercial	$2,538.00
Rate for Payer: Midlands Choice Commercial	$2,368.80
Rate for Payer: Partners Health Alliance Commercial	$2,538.00
Rate for Payer: United Healthcare Commercial	$1,548.45

58180 SUPRACERVICAL ABD HYSTERECTOMY

Professional

Both

$2,961.00

Service Code	CPT 58180
Hospital Charge Code	8378895
Hospital Revenue Code	975
Min. Negotiated Rate	$1,474.42
Max. Negotiated Rate	$2,220.75
Rate for Payer: Cash Price	$2,368.80
Rate for Payer: Cash Price	$2,368.80
Rate for Payer: Medical Associates Commercial	$2,220.75
Rate for Payer: Midlands Choice Commercial	$2,072.70
Rate for Payer: Partners Health Alliance Commercial	$2,220.75
Rate for Payer: United Healthcare Commercial	$1,474.42

58262 VAG HYS <250G W/REMOVAL T/O

Professional

Both

$3,054.00

Service Code	CPT 58262
Hospital Charge Code	8378899
Hospital Revenue Code	975
Min. Negotiated Rate	$1,423.70
Max. Negotiated Rate	$2,290.50
Rate for Payer: Cash Price	$2,443.20
Rate for Payer: Cash Price	$2,443.20
Rate for Payer: Medical Associates Commercial	$2,290.50
Rate for Payer: Midlands Choice Commercial	$2,137.80
Rate for Payer: Partners Health Alliance Commercial	$2,290.50
Rate for Payer: United Healthcare Commercial	$1,423.70

58291 VAG HYST > 250G W/ REMOVAL T/O

Professional

Both

$4,112.00

Service Code	CPT 58291
Hospital Charge Code	8378900
Hospital Revenue Code	975
Min. Negotiated Rate	$1,922.45
Max. Negotiated Rate	$3,084.00
Rate for Payer: Cash Price	$3,289.60
Rate for Payer: Cash Price	$3,289.60
Rate for Payer: Medical Associates Commercial	$3,084.00
Rate for Payer: Midlands Choice Commercial	$2,878.40
Rate for Payer: Partners Health Alliance Commercial	$3,084.00
Rate for Payer: United Healthcare Commercial	$1,922.45

58300 IUD INSERTION

Professional

Both

$240.00

Service Code	CPT 58300
Hospital Charge Code	8069024
Hospital Revenue Code	975
Min. Negotiated Rate	$139.09
Max. Negotiated Rate	$180.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Medical Associates Commercial	$180.00
Rate for Payer: Midlands Choice Commercial	$168.00
Rate for Payer: Partners Health Alliance Commercial	$180.00
Rate for Payer: United Healthcare Commercial	$139.09

58340 Catheterization/introduction of saline/contrast during hysterosalpingography

Professional

Both

$645.00

Service Code	CPT 58340
Hospital Charge Code	8799201
Hospital Revenue Code	975
Min. Negotiated Rate	$291.01
Max. Negotiated Rate	$483.75
Rate for Payer: Cash Price	$516.00
Rate for Payer: Cash Price	$516.00
Rate for Payer: Medical Associates Commercial	$483.75
Rate for Payer: Midlands Choice Commercial	$451.50
Rate for Payer: Partners Health Alliance Commercial	$483.75
Rate for Payer: United Healthcare Commercial	$291.01

58350 Chromotubation of oviduct

Professional

Both

$422.00

Service Code	CPT 58350
Hospital Charge Code	8799202
Hospital Revenue Code	975
Min. Negotiated Rate	$190.82
Max. Negotiated Rate	$316.50
Rate for Payer: Cash Price	$337.60
Rate for Payer: Cash Price	$337.60
Rate for Payer: Medical Associates Commercial	$316.50
Rate for Payer: Midlands Choice Commercial	$295.40
Rate for Payer: Partners Health Alliance Commercial	$316.50
Rate for Payer: United Healthcare Commercial	$190.82

58541 LAP SUPRACERVICAL HYST <250G

Professional

Both

$2,376.00

Service Code	CPT 58541
Hospital Charge Code	8378896
Hospital Revenue Code	975
Min. Negotiated Rate	$1,117.10
Max. Negotiated Rate	$1,782.00
Rate for Payer: Cash Price	$1,900.80
Rate for Payer: Cash Price	$1,900.80
Rate for Payer: Medical Associates Commercial	$1,782.00
Rate for Payer: Midlands Choice Commercial	$1,663.20
Rate for Payer: Partners Health Alliance Commercial	$1,782.00
Rate for Payer: United Healthcare Commercial	$1,117.10

58542 LAP SUPRACERVICAL HIST <250G T/O

Professional

Both

$2,714.00

Service Code	CPT 58542
Hospital Charge Code	8378897
Hospital Revenue Code	975
Min. Negotiated Rate	$1,270.91
Max. Negotiated Rate	$2,035.50
Rate for Payer: Cash Price	$2,171.20
Rate for Payer: Cash Price	$2,171.20
Rate for Payer: Medical Associates Commercial	$2,035.50
Rate for Payer: Midlands Choice Commercial	$1,899.80
Rate for Payer: Partners Health Alliance Commercial	$2,035.50
Rate for Payer: United Healthcare Commercial	$1,270.91

58544 LAP SUPRACERVICAL HYST >250G

Professional

Both

$2,989.00

Service Code	CPT 58544
Hospital Charge Code	8378898
Hospital Revenue Code	975
Min. Negotiated Rate	$1,389.74
Max. Negotiated Rate	$2,241.75
Rate for Payer: Cash Price	$2,391.20
Rate for Payer: Cash Price	$2,391.20
Rate for Payer: Medical Associates Commercial	$2,241.75
Rate for Payer: Midlands Choice Commercial	$2,092.30
Rate for Payer: Partners Health Alliance Commercial	$2,241.75
Rate for Payer: United Healthcare Commercial	$1,389.74

58552 LAVH <250G W/REMOVAL T/O

Professional

Both

$3,279.00

Service Code	CPT 58552
Hospital Charge Code	8378901
Hospital Revenue Code	975
Min. Negotiated Rate	$1,510.03
Max. Negotiated Rate	$2,459.25
Rate for Payer: Cash Price	$2,623.20
Rate for Payer: Cash Price	$2,623.20
Rate for Payer: Medical Associates Commercial	$2,459.25
Rate for Payer: Midlands Choice Commercial	$2,295.30
Rate for Payer: Partners Health Alliance Commercial	$2,459.25
Rate for Payer: United Healthcare Commercial	$1,510.03

58554 LAVH >250G W/REMOVAL T/O

Professional

Both

$4,407.00

Service Code	CPT 58554
Hospital Charge Code	8378902
Hospital Revenue Code	975
Min. Negotiated Rate	$2,019.57
Max. Negotiated Rate	$3,305.25
Rate for Payer: Cash Price	$3,525.60
Rate for Payer: Cash Price	$3,525.60
Rate for Payer: Medical Associates Commercial	$3,305.25
Rate for Payer: Midlands Choice Commercial	$3,084.90
Rate for Payer: Partners Health Alliance Commercial	$3,305.25
Rate for Payer: United Healthcare Commercial	$2,019.57

58555 HYSTEROSCOPY; DIAGNOSTIC

Professional

Both

$887.00

Service Code	CPT 58555
Hospital Charge Code	8378879
Hospital Revenue Code	975
Min. Negotiated Rate	$487.49
Max. Negotiated Rate	$665.25
Rate for Payer: Cash Price	$709.60
Rate for Payer: Cash Price	$709.60
Rate for Payer: Medical Associates Commercial	$665.25
Rate for Payer: Midlands Choice Commercial	$620.90
Rate for Payer: Partners Health Alliance Commercial	$665.25
Rate for Payer: United Healthcare Commercial	$487.49

58559 HYSTEROSCOPY W/LYSIS OF ADHESION

Professional

Both

$966.00

Service Code	CPT 58559
Hospital Charge Code	8378881
Hospital Revenue Code	975
Min. Negotiated Rate	$441.60
Max. Negotiated Rate	$724.50
Rate for Payer: Cash Price	$772.80
Rate for Payer: Cash Price	$772.80
Rate for Payer: Medical Associates Commercial	$724.50
Rate for Payer: Midlands Choice Commercial	$676.20
Rate for Payer: Partners Health Alliance Commercial	$724.50
Rate for Payer: United Healthcare Commercial	$441.60

58561 Hysteroscopy surgical; w/ removal of leiomyomata

Professional

Both

$1,201.00

Service Code	CPT 58561
Hospital Charge Code	8799203
Hospital Revenue Code	975
Min. Negotiated Rate	$555.31
Max. Negotiated Rate	$900.75
Rate for Payer: Cash Price	$960.80
Rate for Payer: Cash Price	$960.80
Rate for Payer: Medical Associates Commercial	$900.75
Rate for Payer: Midlands Choice Commercial	$840.70
Rate for Payer: Partners Health Alliance Commercial	$900.75
Rate for Payer: United Healthcare Commercial	$555.31

58563 HSC W/ENDOMETRIAL ABLATION

Professional

Both

$5,245.00

Service Code	CPT 58563
Hospital Charge Code	8378882
Hospital Revenue Code	975
Min. Negotiated Rate	$2,917.52
Max. Negotiated Rate	$3,933.75
Rate for Payer: Cash Price	$4,196.00
Rate for Payer: Cash Price	$4,196.00
Rate for Payer: Medical Associates Commercial	$3,933.75
Rate for Payer: Midlands Choice Commercial	$3,671.50
Rate for Payer: Partners Health Alliance Commercial	$3,933.75
Rate for Payer: United Healthcare Commercial	$2,917.52

58565 HSC W/BILAT/FALLOPIAN TUBE

Professional

Both

$6,201.00

Service Code	CPT 58565
Hospital Charge Code	8378883
Hospital Revenue Code	975
Min. Negotiated Rate	$2,711.79
Max. Negotiated Rate	$4,650.75
Rate for Payer: Cash Price	$4,960.80
Rate for Payer: Cash Price	$4,960.80
Rate for Payer: Medical Associates Commercial	$4,650.75
Rate for Payer: Midlands Choice Commercial	$4,340.70
Rate for Payer: Partners Health Alliance Commercial	$4,650.75
Rate for Payer: United Healthcare Commercial	$2,711.79

58570 LAP TOTAL HYST FOR UTERUS <250G

Professional

Both

$2,587.00

Service Code	CPT 58570
Hospital Charge Code	8378903
Hospital Revenue Code	975
Min. Negotiated Rate	$1,217.79
Max. Negotiated Rate	$1,940.25
Rate for Payer: Cash Price	$2,069.60
Rate for Payer: Cash Price	$2,069.60
Rate for Payer: Medical Associates Commercial	$1,940.25
Rate for Payer: Midlands Choice Commercial	$1,810.90
Rate for Payer: Partners Health Alliance Commercial	$1,940.25
Rate for Payer: United Healthcare Commercial	$1,217.79

58571 LAP TOTAL HYST W/REMOVAL TUBES AND/OR OVERIES

Professional

Both

$2,991.00

Service Code	CPT 58571
Hospital Charge Code	8378904
Hospital Revenue Code	975
Min. Negotiated Rate	$1,373.06
Max. Negotiated Rate	$2,243.25
Rate for Payer: Cash Price	$2,392.80
Rate for Payer: Cash Price	$2,392.80
Rate for Payer: Medical Associates Commercial	$2,243.25
Rate for Payer: Midlands Choice Commercial	$2,093.70
Rate for Payer: Partners Health Alliance Commercial	$2,243.25
Rate for Payer: United Healthcare Commercial	$1,373.06

58600 TUBAL LIGATION

Professional

Both

$1,201.00

Service Code	CPT 58600
Hospital Charge Code	8068988
Hospital Revenue Code	975
Min. Negotiated Rate	$564.38
Max. Negotiated Rate	$900.75
Rate for Payer: Cash Price	$960.80
Rate for Payer: Cash Price	$960.80
Rate for Payer: Medical Associates Commercial	$900.75
Rate for Payer: Midlands Choice Commercial	$840.70
Rate for Payer: Partners Health Alliance Commercial	$900.75
Rate for Payer: United Healthcare Commercial	$564.38

58605 TUBAL LIGATION POST PARTUM

Professional

Both

$1,088.00

Service Code	CPT 58605
Hospital Charge Code	8068982
Hospital Revenue Code	975
Min. Negotiated Rate	$510.88
Max. Negotiated Rate	$816.00
Rate for Payer: Cash Price	$870.40
Rate for Payer: Cash Price	$870.40
Rate for Payer: Medical Associates Commercial	$816.00
Rate for Payer: Midlands Choice Commercial	$761.60
Rate for Payer: Partners Health Alliance Commercial	$816.00
Rate for Payer: United Healthcare Commercial	$510.88

58611 TUBAL LIGATION W/OTHER PROC

Professional

Both

$255.00

Service Code	CPT 58611
Hospital Charge Code	8069138
Hospital Revenue Code	975
Min. Negotiated Rate	$118.42
Max. Negotiated Rate	$191.25
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Medical Associates Commercial	$191.25
Rate for Payer: Midlands Choice Commercial	$178.50
Rate for Payer: Partners Health Alliance Commercial	$191.25
Rate for Payer: United Healthcare Commercial	$118.42

Know your out-of-pocket cost for care.

All Charges