Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

58660 LAP W/LYSIS OF ADHESIONS-FEMALE

Professional

Both

$2,237.00

Service Code	CPT 58660
Hospital Charge Code	8378884
Hospital Revenue Code	975
Min. Negotiated Rate	$1,036.14
Max. Negotiated Rate	$1,677.75
Rate for Payer: Cash Price	$1,789.60
Rate for Payer: Cash Price	$1,789.60
Rate for Payer: Medical Associates Commercial	$1,677.75
Rate for Payer: Midlands Choice Commercial	$1,565.90
Rate for Payer: Partners Health Alliance Commercial	$1,677.75
Rate for Payer: United Healthcare Commercial	$1,036.14

58661 LAP W/SALP-OOPHORECTOMY

Professional

Both

$2,160.00

Service Code	CPT 58661
Hospital Charge Code	8378885
Hospital Revenue Code	975
Min. Negotiated Rate	$998.51
Max. Negotiated Rate	$1,620.00
Rate for Payer: Cash Price	$1,728.00
Rate for Payer: Cash Price	$1,728.00
Rate for Payer: Medical Associates Commercial	$1,620.00
Rate for Payer: Midlands Choice Commercial	$1,512.00
Rate for Payer: Partners Health Alliance Commercial	$1,620.00
Rate for Payer: United Healthcare Commercial	$998.51

58662 LAP W/FULGURATION OF LESION

Professional

Both

$2,360.00

Service Code	CPT 58662
Hospital Charge Code	8378886
Hospital Revenue Code	975
Min. Negotiated Rate	$1,091.04
Max. Negotiated Rate	$1,770.00
Rate for Payer: Cash Price	$1,888.00
Rate for Payer: Cash Price	$1,888.00
Rate for Payer: Medical Associates Commercial	$1,770.00
Rate for Payer: Midlands Choice Commercial	$1,652.00
Rate for Payer: Partners Health Alliance Commercial	$1,770.00
Rate for Payer: United Healthcare Commercial	$1,091.04

58670 LAP TUBAL W/ DESTRUCTION OF OVIDUCTS

Professional

Both

$1,207.00

Service Code	CPT 58670
Hospital Charge Code	8069144
Hospital Revenue Code	975
Min. Negotiated Rate	$565.66
Max. Negotiated Rate	$905.25
Rate for Payer: Cash Price	$965.60
Rate for Payer: Cash Price	$965.60
Rate for Payer: Medical Associates Commercial	$905.25
Rate for Payer: Midlands Choice Commercial	$844.90
Rate for Payer: Partners Health Alliance Commercial	$905.25
Rate for Payer: United Healthcare Commercial	$565.66

58671 Laparoscopy surgical; w/ occlusion of oviducts by device

Professional

Both

$1,197.00

Service Code	CPT 58671
Hospital Charge Code	8799204
Hospital Revenue Code	975
Min. Negotiated Rate	$564.90
Max. Negotiated Rate	$897.75
Rate for Payer: Cash Price	$957.60
Rate for Payer: Cash Price	$957.60
Rate for Payer: Medical Associates Commercial	$897.75
Rate for Payer: Midlands Choice Commercial	$837.90
Rate for Payer: Partners Health Alliance Commercial	$897.75
Rate for Payer: United Healthcare Commercial	$564.90

58720 SALPINGO-OOPHORECTOMY

Professional

Both

$2,459.00

Service Code	CPT 58720
Hospital Charge Code	8069040
Hospital Revenue Code	975
Min. Negotiated Rate	$1,139.22
Max. Negotiated Rate	$1,844.25
Rate for Payer: Cash Price	$1,967.20
Rate for Payer: Cash Price	$1,967.20
Rate for Payer: Medical Associates Commercial	$1,844.25
Rate for Payer: Midlands Choice Commercial	$1,721.30
Rate for Payer: Partners Health Alliance Commercial	$1,844.25
Rate for Payer: United Healthcare Commercial	$1,139.22

58925 OVARIAN CYSTECTOMY W/HYSTERECT

Professional

Both

$2,484.00

Service Code	CPT 58925
Hospital Charge Code	8068997
Hospital Revenue Code	975
Min. Negotiated Rate	$1,157.39
Max. Negotiated Rate	$1,863.00
Rate for Payer: Cash Price	$1,987.20
Rate for Payer: Cash Price	$1,987.20
Rate for Payer: Medical Associates Commercial	$1,863.00
Rate for Payer: Midlands Choice Commercial	$1,738.80
Rate for Payer: Partners Health Alliance Commercial	$1,863.00
Rate for Payer: United Healthcare Commercial	$1,157.39

58940 OOPHORECTOMY

Professional

Both

$1,754.00

Service Code	CPT 58940
Hospital Charge Code	8069191
Hospital Revenue Code	975
Min. Negotiated Rate	$822.78
Max. Negotiated Rate	$1,315.50
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Medical Associates Commercial	$1,315.50
Rate for Payer: Midlands Choice Commercial	$1,227.80
Rate for Payer: Partners Health Alliance Commercial	$1,315.50
Rate for Payer: United Healthcare Commercial	$822.78

59160 DC POSTPARTUM

Professional

Both

$682.00

Service Code	CPT 59160
Hospital Charge Code	8378906
Hospital Revenue Code	975
Min. Negotiated Rate	$356.61
Max. Negotiated Rate	$511.50
Rate for Payer: Cash Price	$545.60
Rate for Payer: Cash Price	$545.60
Rate for Payer: Medical Associates Commercial	$511.50
Rate for Payer: Midlands Choice Commercial	$477.40
Rate for Payer: Partners Health Alliance Commercial	$511.50
Rate for Payer: United Healthcare Commercial	$356.61

59514 C-SECTION

Professional

Both

$3,100.00

Service Code	CPT 59514
Hospital Charge Code	8069081
Hospital Revenue Code	975
Min. Negotiated Rate	$976.99
Max. Negotiated Rate	$2,325.00
Rate for Payer: Cash Price	$2,480.00
Rate for Payer: Cash Price	$2,480.00
Rate for Payer: Medical Associates Commercial	$2,325.00
Rate for Payer: Midlands Choice Commercial	$2,170.00
Rate for Payer: Partners Health Alliance Commercial	$2,325.00
Rate for Payer: United Healthcare Commercial	$976.99

59820 SURG TX MISSED ABORT 1ST TRIMESTER

Professional

Both

$1,273.00

Service Code	CPT 59820
Hospital Charge Code	8378888
Hospital Revenue Code	975
Min. Negotiated Rate	$610.32
Max. Negotiated Rate	$954.75
Rate for Payer: Cash Price	$1,018.40
Rate for Payer: Cash Price	$1,018.40
Rate for Payer: Medical Associates Commercial	$954.75
Rate for Payer: Midlands Choice Commercial	$891.10
Rate for Payer: Partners Health Alliance Commercial	$954.75
Rate for Payer: United Healthcare Commercial	$610.32

59820 Treatment of missed abortion- 1st trimester

Professional

Both

$1,270.00

Service Code	CPT 59820
Hospital Charge Code	8799205
Hospital Revenue Code	975
Min. Negotiated Rate	$610.32
Max. Negotiated Rate	$952.50
Rate for Payer: Cash Price	$1,016.00
Rate for Payer: Cash Price	$1,016.00
Rate for Payer: Medical Associates Commercial	$952.50
Rate for Payer: Midlands Choice Commercial	$889.00
Rate for Payer: Partners Health Alliance Commercial	$952.50
Rate for Payer: United Healthcare Commercial	$610.32

60220 THYROID LOBECTOMY TOTAL

Professional

Both

$2,370.00

Service Code	CPT 60220
Hospital Charge Code	8068978
Hospital Revenue Code	975
Min. Negotiated Rate	$1,069.02
Max. Negotiated Rate	$1,777.50
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Medical Associates Commercial	$1,777.50
Rate for Payer: Midlands Choice Commercial	$1,659.00
Rate for Payer: Partners Health Alliance Commercial	$1,777.50
Rate for Payer: United Healthcare Commercial	$1,069.02

62321 Spinal injection steroid- cervical/thoracic with fluoroscopic guidance

Professional

Both

$860.00

Service Code	CPT 62321
Hospital Charge Code	8799206
Hospital Revenue Code	975
Min. Negotiated Rate	$391.44
Max. Negotiated Rate	$645.00
Rate for Payer: Cash Price	$688.00
Rate for Payer: Cash Price	$688.00
Rate for Payer: Medical Associates Commercial	$645.00
Rate for Payer: Midlands Choice Commercial	$602.00
Rate for Payer: Partners Health Alliance Commercial	$645.00
Rate for Payer: United Healthcare Commercial	$391.44

62323 Spinal injection steroid- lumbar/sacral with fluoroscopic guidance

Professional

Both

$808.00

Service Code	CPT 62323
Hospital Charge Code	8799211
Hospital Revenue Code	975
Min. Negotiated Rate	$386.45
Max. Negotiated Rate	$606.00
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cash Price	$646.40
Rate for Payer: Medical Associates Commercial	$606.00
Rate for Payer: Midlands Choice Commercial	$565.60
Rate for Payer: Partners Health Alliance Commercial	$606.00
Rate for Payer: United Healthcare Commercial	$386.45

64405 Occipital nerve block (can only be reported once-even if bilateral)

Professional

Both

$332.00

Service Code	CPT 64405
Hospital Charge Code	8799212
Hospital Revenue Code	975
Min. Negotiated Rate	$107.60
Max. Negotiated Rate	$249.00
Rate for Payer: Cash Price	$265.60
Rate for Payer: Cash Price	$265.60
Rate for Payer: Medical Associates Commercial	$249.00
Rate for Payer: Midlands Choice Commercial	$232.40
Rate for Payer: Partners Health Alliance Commercial	$249.00
Rate for Payer: United Healthcare Commercial	$107.60

64451 INJ AA/STRD Nerves NRVTG SI Joint W/IMG

Professional

Both

$699.00

Service Code	CPT 64451
Hospital Charge Code	8801477
Hospital Revenue Code	975
Min. Negotiated Rate	$317.70
Max. Negotiated Rate	$524.25
Rate for Payer: Cash Price	$559.20
Rate for Payer: Cash Price	$559.20
Rate for Payer: Medical Associates Commercial	$524.25
Rate for Payer: Midlands Choice Commercial	$489.30
Rate for Payer: Partners Health Alliance Commercial	$524.25
Rate for Payer: United Healthcare Commercial	$317.70

64454 Injection genicular nerve branches incl/ imaging when guidance

Professional

Both

$706.00

Service Code	CPT 64454
Hospital Charge Code	8799213
Hospital Revenue Code	975
Min. Negotiated Rate	$320.83
Max. Negotiated Rate	$529.50
Rate for Payer: Cash Price	$564.80
Rate for Payer: Cash Price	$564.80
Rate for Payer: Medical Associates Commercial	$529.50
Rate for Payer: Midlands Choice Commercial	$494.20
Rate for Payer: Partners Health Alliance Commercial	$529.50
Rate for Payer: United Healthcare Commercial	$320.83

64479 INJ Foramen Epidural C/T

Professional

Both

$847.00

Service Code	CPT 64479
Hospital Charge Code	8801475
Hospital Revenue Code	975
Min. Negotiated Rate	$386.38
Max. Negotiated Rate	$635.25
Rate for Payer: Cash Price	$677.60
Rate for Payer: Cash Price	$677.60
Rate for Payer: Medical Associates Commercial	$635.25
Rate for Payer: Midlands Choice Commercial	$592.90
Rate for Payer: Partners Health Alliance Commercial	$635.25
Rate for Payer: United Healthcare Commercial	$386.38

64480 INJ Foramen Epidural Add-On

Professional

Both

$421.00

Service Code	CPT 64480
Hospital Charge Code	8801476
Hospital Revenue Code	975
Min. Negotiated Rate	$192.16
Max. Negotiated Rate	$315.75
Rate for Payer: Cash Price	$336.80
Rate for Payer: Cash Price	$336.80
Rate for Payer: Medical Associates Commercial	$315.75
Rate for Payer: Midlands Choice Commercial	$294.70
Rate for Payer: Partners Health Alliance Commercial	$315.75
Rate for Payer: United Healthcare Commercial	$192.16

64561 PERCUTANEOUS IMPLANT NEUROELECTRODES

Professional

Both

$2,732.00

Service Code	CPT 64561
Hospital Charge Code	8068904
Hospital Revenue Code	975
Min. Negotiated Rate	$1,129.50
Max. Negotiated Rate	$2,049.00
Rate for Payer: Cash Price	$2,185.60
Rate for Payer: Cash Price	$2,185.60
Rate for Payer: Medical Associates Commercial	$2,049.00
Rate for Payer: Midlands Choice Commercial	$1,912.40
Rate for Payer: Partners Health Alliance Commercial	$2,049.00
Rate for Payer: United Healthcare Commercial	$1,129.50

64581 INCISION FOR IMPLANT NEUROELECTRODES

Professional

Both

$2,232.00

Service Code	CPT 64581
Hospital Charge Code	8068905
Hospital Revenue Code	975
Min. Negotiated Rate	$1,025.73
Max. Negotiated Rate	$1,674.00
Rate for Payer: Cash Price	$1,785.60
Rate for Payer: Cash Price	$1,785.60
Rate for Payer: Medical Associates Commercial	$1,674.00
Rate for Payer: Midlands Choice Commercial	$1,562.40
Rate for Payer: Partners Health Alliance Commercial	$1,674.00
Rate for Payer: United Healthcare Commercial	$1,025.73

64590 INSERTION/REPLACEMENT OF NEUROSTIMULATOR GEN OR REC

Professional

Both

$882.00

Service Code	CPT 64590
Hospital Charge Code	8068906
Hospital Revenue Code	975
Min. Negotiated Rate	$400.66
Max. Negotiated Rate	$661.50
Rate for Payer: Cash Price	$705.60
Rate for Payer: Cash Price	$705.60
Rate for Payer: Medical Associates Commercial	$661.50
Rate for Payer: Midlands Choice Commercial	$617.40
Rate for Payer: Partners Health Alliance Commercial	$661.50
Rate for Payer: United Healthcare Commercial	$400.66

64624 Destruction by neurolytic agent genicular nerve branches inc imaging guidance

Professional

Both

$1,350.00

Service Code	CPT 64624
Hospital Charge Code	8799214
Hospital Revenue Code	975
Min. Negotiated Rate	$612.69
Max. Negotiated Rate	$1,012.50
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Medical Associates Commercial	$1,012.50
Rate for Payer: Midlands Choice Commercial	$945.00
Rate for Payer: Partners Health Alliance Commercial	$1,012.50
Rate for Payer: United Healthcare Commercial	$612.69

64625 Radiofrequency ablation of sacroiliac joint

Professional

Both

$1,649.00

Service Code	CPT 64625
Hospital Charge Code	8801481
Hospital Revenue Code	975
Min. Negotiated Rate	$749.84
Max. Negotiated Rate	$1,236.75
Rate for Payer: Cash Price	$1,319.20
Rate for Payer: Cash Price	$1,319.20
Rate for Payer: Medical Associates Commercial	$1,236.75
Rate for Payer: Midlands Choice Commercial	$1,154.30
Rate for Payer: Partners Health Alliance Commercial	$1,236.75
Rate for Payer: United Healthcare Commercial	$749.84

Know your out-of-pocket cost for care.

All Charges