Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

1.6MM KIRSCHNER WIRE X 150MM

Facility

$159.00

Service Code	HCPCS C1763
Hospital Charge Code	8748487
Hospital Revenue Code	278
Min. Negotiated Rate	$71.55
Max. Negotiated Rate	$143.10
Rate for Payer: Aetna of IA Commercial	$143.10
Rate for Payer: Aetna of IA Medical Rental Products	$143.10
Rate for Payer: Aetna of IA Medicare	$90.63
Rate for Payer: Amerigroup Medicaid	$91.71
Rate for Payer: Amerigroup Medicare	$72.27
Rate for Payer: Cash Price	$127.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$119.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$71.55
Rate for Payer: Iowa Total Care Managed Medicaid	$90.82
Rate for Payer: Medical Associates Commercial	$119.25
Rate for Payer: Medical Associates Managed Medicare	$71.55
Rate for Payer: Midlands Choice Commercial	$111.30
Rate for Payer: Molina Healthcare Managed Medicaid	$92.16
Rate for Payer: Partners Health Alliance Commercial	$82.28
Rate for Payer: United Healthcare Commercial	$143.10
Rate for Payer: United Healthcare Managed Medicare	$93.81

1.6MM KIRSCHNER WIRE X 150MM

Facility

$159.00

Service Code	HCPCS C1763
Hospital Charge Code	8748487
Hospital Revenue Code	278
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$143.10
Rate for Payer: Aetna of IA Commercial	$143.10
Rate for Payer: Aetna of IA Medical Rental Products	$143.10
Rate for Payer: Cash Price	$127.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$119.25
Rate for Payer: Medical Associates Commercial	$119.25
Rate for Payer: Midlands Choice Commercial	$111.30
Rate for Payer: United Healthcare Commercial	$143.10

17110 Destruction of benign lesions up to 14 lesions

Professional

Both

$366.00

Service Code	CPT 17110
Hospital Charge Code	8799108
Hospital Revenue Code	975
Min. Negotiated Rate	$47.14
Max. Negotiated Rate	$274.50
Rate for Payer: Amerigroup Medicaid	$47.61
Rate for Payer: Cash Price	$292.80
Rate for Payer: Cash Price	$292.80
Rate for Payer: Iowa Total Care Managed Medicaid	$47.14
Rate for Payer: Medical Associates Commercial	$274.50
Rate for Payer: Midlands Choice Commercial	$256.20
Rate for Payer: Molina Healthcare Managed Medicaid	$47.38
Rate for Payer: Partners Health Alliance Commercial	$274.50
Rate for Payer: United Healthcare Commercial	$167.55
Rate for Payer: Wellmark IA HMO WHPI	$208.50
Rate for Payer: Wellmark IA PPO	$245.20

18MMX15MMX15MM SNIPER STAPLE

Facility

$1,629.00

Service Code	HCPCS C1713
Hospital Charge Code	8857932
Hospital Revenue Code	278
Min. Negotiated Rate	$733.05
Max. Negotiated Rate	$1,466.10
Rate for Payer: Aetna of IA Commercial	$1,466.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,466.10
Rate for Payer: Aetna of IA Medicare	$928.53
Rate for Payer: Amerigroup Medicaid	$939.61
Rate for Payer: Amerigroup Medicare	$740.38
Rate for Payer: Cash Price	$1,303.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,221.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$733.05
Rate for Payer: Iowa Total Care Managed Medicaid	$930.48
Rate for Payer: Medical Associates Commercial	$1,221.75
Rate for Payer: Medical Associates Managed Medicare	$733.05
Rate for Payer: Midlands Choice Commercial	$1,140.30
Rate for Payer: Molina Healthcare Managed Medicaid	$944.17
Rate for Payer: Partners Health Alliance Commercial	$843.01
Rate for Payer: United Healthcare Commercial	$1,466.10
Rate for Payer: United Healthcare Managed Medicare	$961.11

18MMX15MMX15MM SNIPER STAPLE

Facility

$1,629.00

Service Code	HCPCS C1713
Hospital Charge Code	8857932
Hospital Revenue Code	278
Min. Negotiated Rate	$1,140.30
Max. Negotiated Rate	$1,466.10
Rate for Payer: Aetna of IA Commercial	$1,466.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,466.10
Rate for Payer: Cash Price	$1,303.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,221.75
Rate for Payer: Medical Associates Commercial	$1,221.75
Rate for Payer: Midlands Choice Commercial	$1,140.30
Rate for Payer: United Healthcare Commercial	$1,466.10

19120 REMOVAL OF BREAST LESION

Professional

Both

$1,643.00

Service Code	CPT 19120
Hospital Charge Code	8069146
Hospital Revenue Code	975
Min. Negotiated Rate	$331.22
Max. Negotiated Rate	$1,232.25
Rate for Payer: Amerigroup Medicaid	$334.47
Rate for Payer: Cash Price	$1,314.40
Rate for Payer: Cash Price	$1,314.40
Rate for Payer: Iowa Total Care Managed Medicaid	$331.22
Rate for Payer: Medical Associates Commercial	$1,232.25
Rate for Payer: Midlands Choice Commercial	$1,150.10
Rate for Payer: Molina Healthcare Managed Medicaid	$332.85
Rate for Payer: Partners Health Alliance Commercial	$1,232.25
Rate for Payer: United Healthcare Commercial	$753.49
Rate for Payer: Wellmark IA HMO WHPI	$956.00
Rate for Payer: Wellmark IA PPO	$1,124.70

19301 MASTECTOMY PARTIAL

Professional

Both

$2,189.00

Service Code	CPT 19301
Hospital Charge Code	8069176
Hospital Revenue Code	975
Min. Negotiated Rate	$333.13
Max. Negotiated Rate	$1,641.75
Rate for Payer: Amerigroup Medicaid	$336.40
Rate for Payer: Cash Price	$1,751.20
Rate for Payer: Cash Price	$1,751.20
Rate for Payer: Iowa Total Care Managed Medicaid	$333.13
Rate for Payer: Medical Associates Commercial	$1,641.75
Rate for Payer: Midlands Choice Commercial	$1,532.30
Rate for Payer: Molina Healthcare Managed Medicaid	$334.76
Rate for Payer: Partners Health Alliance Commercial	$1,641.75
Rate for Payer: United Healthcare Commercial	$985.14
Rate for Payer: Wellmark IA HMO WHPI	$1,211.20
Rate for Payer: Wellmark IA PPO	$1,425.00

19302 MASTECTOMY PART W LYMPHADENECT

Professional

Both

$3,021.00

Service Code	CPT 19302
Hospital Charge Code	8069192
Hospital Revenue Code	975
Min. Negotiated Rate	$711.32
Max. Negotiated Rate	$2,265.75
Rate for Payer: Amerigroup Medicaid	$718.29
Rate for Payer: Cash Price	$2,416.80
Rate for Payer: Cash Price	$2,416.80
Rate for Payer: Iowa Total Care Managed Medicaid	$711.32
Rate for Payer: Medical Associates Commercial	$2,265.75
Rate for Payer: Midlands Choice Commercial	$2,114.70
Rate for Payer: Molina Healthcare Managed Medicaid	$714.80
Rate for Payer: Partners Health Alliance Commercial	$2,265.75
Rate for Payer: United Healthcare Commercial	$1,353.60
Rate for Payer: Wellmark IA HMO WHPI	$1,662.80
Rate for Payer: Wellmark IA PPO	$1,956.20

20240 Biopsy of bone; open superficial

Professional

Both

$503.00

Service Code	CPT 20240
Hospital Charge Code	8799109
Hospital Revenue Code	975
Min. Negotiated Rate	$215.39
Max. Negotiated Rate	$377.25
Rate for Payer: Amerigroup Medicaid	$217.51
Rate for Payer: Cash Price	$402.40
Rate for Payer: Cash Price	$402.40
Rate for Payer: Iowa Total Care Managed Medicaid	$215.39
Rate for Payer: Medical Associates Commercial	$377.25
Rate for Payer: Midlands Choice Commercial	$352.10
Rate for Payer: Molina Healthcare Managed Medicaid	$216.45
Rate for Payer: Partners Health Alliance Commercial	$377.25
Rate for Payer: United Healthcare Commercial	$225.58
Rate for Payer: Wellmark IA HMO WHPI	$262.90
Rate for Payer: Wellmark IA PPO	$309.30

20526 Carpal tunnel injection

Professional

Both

$257.00

Service Code	CPT 20526
Hospital Charge Code	8799110
Hospital Revenue Code	975
Min. Negotiated Rate	$58.60
Max. Negotiated Rate	$192.75
Rate for Payer: Amerigroup Medicaid	$59.17
Rate for Payer: Cash Price	$205.60
Rate for Payer: Cash Price	$205.60
Rate for Payer: Iowa Total Care Managed Medicaid	$58.60
Rate for Payer: Medical Associates Commercial	$192.75
Rate for Payer: Midlands Choice Commercial	$179.90
Rate for Payer: Molina Healthcare Managed Medicaid	$58.89
Rate for Payer: Partners Health Alliance Commercial	$192.75
Rate for Payer: United Healthcare Commercial	$118.43
Rate for Payer: Wellmark IA HMO WHPI	$156.00
Rate for Payer: Wellmark IA PPO	$183.50

20600 Arthrocentesis- injection small joint/bursa (fingers/toes)

Professional

Both

$161.00

Service Code	CPT 20600
Hospital Charge Code	8799111
Hospital Revenue Code	975
Min. Negotiated Rate	$52.35
Max. Negotiated Rate	$120.75
Rate for Payer: Amerigroup Medicaid	$52.86
Rate for Payer: Cash Price	$128.80
Rate for Payer: Cash Price	$128.80
Rate for Payer: Iowa Total Care Managed Medicaid	$52.35
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: Molina Healthcare Managed Medicaid	$52.60
Rate for Payer: Partners Health Alliance Commercial	$120.75
Rate for Payer: United Healthcare Commercial	$76.45
Rate for Payer: Wellmark IA HMO WHPI	$101.90
Rate for Payer: Wellmark IA PPO	$119.90

20605 Arthrocentesis- injection intermediate joint/bursa (TMJ wrist elbow ankle)

Professional

Both

$168.00

Service Code	CPT 20605
Hospital Charge Code	8799112
Hospital Revenue Code	975
Min. Negotiated Rate	$57.65
Max. Negotiated Rate	$126.00
Rate for Payer: Amerigroup Medicaid	$58.22
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Iowa Total Care Managed Medicaid	$57.65
Rate for Payer: Medical Associates Commercial	$126.00
Rate for Payer: Midlands Choice Commercial	$117.60
Rate for Payer: Molina Healthcare Managed Medicaid	$57.93
Rate for Payer: Partners Health Alliance Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$79.18
Rate for Payer: Wellmark IA HMO WHPI	$104.40
Rate for Payer: Wellmark IA PPO	$122.80

20611 Drain/injection major joint/bursa w/ ultrasound guidance

Professional

Both

$313.00

Service Code	CPT 20611
Hospital Charge Code	8799113
Hospital Revenue Code	975
Min. Negotiated Rate	$82.51
Max. Negotiated Rate	$234.75
Rate for Payer: Amerigroup Medicaid	$83.32
Rate for Payer: Cash Price	$250.40
Rate for Payer: Cash Price	$250.40
Rate for Payer: Iowa Total Care Managed Medicaid	$82.51
Rate for Payer: Medical Associates Commercial	$234.75
Rate for Payer: Midlands Choice Commercial	$219.10
Rate for Payer: Molina Healthcare Managed Medicaid	$82.91
Rate for Payer: Partners Health Alliance Commercial	$234.75
Rate for Payer: United Healthcare Commercial	$142.64
Rate for Payer: Wellmark IA HMO WHPI	$188.10
Rate for Payer: Wellmark IA PPO	$221.30

20670 Removal implant superficial (separate procedure)

Professional

Both

$1,228.00

Service Code	CPT 20670
Hospital Charge Code	8799114
Hospital Revenue Code	975
Min. Negotiated Rate	$157.84
Max. Negotiated Rate	$921.00
Rate for Payer: Amerigroup Medicaid	$159.39
Rate for Payer: Cash Price	$982.40
Rate for Payer: Cash Price	$982.40
Rate for Payer: Iowa Total Care Managed Medicaid	$157.84
Rate for Payer: Medical Associates Commercial	$921.00
Rate for Payer: Midlands Choice Commercial	$859.60
Rate for Payer: Molina Healthcare Managed Medicaid	$158.62
Rate for Payer: Partners Health Alliance Commercial	$921.00
Rate for Payer: United Healthcare Commercial	$553.30
Rate for Payer: Wellmark IA HMO WHPI	$671.80
Rate for Payer: Wellmark IA PPO	$790.30

20680 Removal implanted device deep

Professional

Both

$2,055.00

Service Code	CPT 20680
Hospital Charge Code	8799115
Hospital Revenue Code	975
Min. Negotiated Rate	$254.61
Max. Negotiated Rate	$1,541.25
Rate for Payer: Amerigroup Medicaid	$257.11
Rate for Payer: Cash Price	$1,644.00
Rate for Payer: Cash Price	$1,644.00
Rate for Payer: Iowa Total Care Managed Medicaid	$254.61
Rate for Payer: Medical Associates Commercial	$1,541.25
Rate for Payer: Midlands Choice Commercial	$1,438.50
Rate for Payer: Molina Healthcare Managed Medicaid	$255.86
Rate for Payer: Partners Health Alliance Commercial	$1,541.25
Rate for Payer: United Healthcare Commercial	$925.36
Rate for Payer: Wellmark IA HMO WHPI	$1,139.10
Rate for Payer: Wellmark IA PPO	$1,340.10

20690 APPLY BONE FIXATION DEVICE 1 PLATE

Professional

Both

$2,009.00

Service Code	CPT 20690
Hospital Charge Code	8799116
Hospital Revenue Code	975
Min. Negotiated Rate	$229.80
Max. Negotiated Rate	$1,506.75
Rate for Payer: Amerigroup Medicaid	$232.05
Rate for Payer: Cash Price	$1,607.20
Rate for Payer: Cash Price	$1,607.20
Rate for Payer: Iowa Total Care Managed Medicaid	$229.80
Rate for Payer: Medical Associates Commercial	$1,506.75
Rate for Payer: Midlands Choice Commercial	$1,406.30
Rate for Payer: Molina Healthcare Managed Medicaid	$230.92
Rate for Payer: Partners Health Alliance Commercial	$1,506.75
Rate for Payer: United Healthcare Commercial	$902.99
Rate for Payer: Wellmark IA HMO WHPI	$1,134.70
Rate for Payer: Wellmark IA PPO	$1,335.00

2.0MM XBRAID TT 100% UHMWPE VIOLET CO-BRAID

Facility

$180.00

Service Code	HCPCS C1713
Hospital Charge Code	8771318
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

2.0MM XBRAID TT 100% UHMWPE VIOLET CO-BRAID

Facility

$180.00

Service Code	HCPCS C1713
Hospital Charge Code	8771318
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

2.0MM XBRAID TT 100% UHMWPE VIOLET CO-BRAID 3910900019

Facility

$100.00

Service Code	HCPCS C1713
Hospital Charge Code	8797132
Hospital Revenue Code	278
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: United Healthcare Commercial	$90.00

2.0MM XBRAID TT 100% UHMWPE VIOLET CO-BRAID 3910900019

Facility

$100.00

Service Code	HCPCS C1713
Hospital Charge Code	8797132
Hospital Revenue Code	278
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Aetna of IA Medicare	$57.00
Rate for Payer: Amerigroup Medicaid	$57.68
Rate for Payer: Amerigroup Medicare	$45.45
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$45.00
Rate for Payer: Iowa Total Care Managed Medicaid	$57.12
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Medical Associates Managed Medicare	$45.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: Molina Healthcare Managed Medicaid	$57.96
Rate for Payer: Partners Health Alliance Commercial	$51.75
Rate for Payer: United Healthcare Commercial	$90.00
Rate for Payer: United Healthcare Managed Medicare	$59.00

21116 Temporomandibular joint injection

Professional

Both

$656.00

Service Code	CPT 21116
Hospital Charge Code	8799117
Hospital Revenue Code	975
Min. Negotiated Rate	$156.23
Max. Negotiated Rate	$492.00
Rate for Payer: Amerigroup Medicaid	$157.77
Rate for Payer: Cash Price	$524.80
Rate for Payer: Cash Price	$524.80
Rate for Payer: Iowa Total Care Managed Medicaid	$156.23
Rate for Payer: Medical Associates Commercial	$492.00
Rate for Payer: Midlands Choice Commercial	$459.20
Rate for Payer: Molina Healthcare Managed Medicaid	$157.00
Rate for Payer: Partners Health Alliance Commercial	$492.00
Rate for Payer: United Healthcare Commercial	$296.18
Rate for Payer: Wellmark IA HMO WHPI	$400.00
Rate for Payer: Wellmark IA PPO	$470.60

21555 EXC NECK LES SUBQ LESS THAN 3 CM

Professional

Both

$1,382.00

Service Code	CPT 21555
Hospital Charge Code	8069117
Hospital Revenue Code	975
Min. Negotiated Rate	$260.86
Max. Negotiated Rate	$1,036.50
Rate for Payer: Amerigroup Medicaid	$263.42
Rate for Payer: Cash Price	$1,105.60
Rate for Payer: Cash Price	$1,105.60
Rate for Payer: Iowa Total Care Managed Medicaid	$260.86
Rate for Payer: Medical Associates Commercial	$1,036.50
Rate for Payer: Midlands Choice Commercial	$967.40
Rate for Payer: Molina Healthcare Managed Medicaid	$262.14
Rate for Payer: Partners Health Alliance Commercial	$1,036.50
Rate for Payer: United Healthcare Commercial	$641.86
Rate for Payer: Wellmark IA HMO WHPI	$825.20
Rate for Payer: Wellmark IA PPO	$970.90

22902 EXC ABD LES SUBQ LESS THAN 3 CM

Professional

Both

$1,461.00

Service Code	CPT 22902
Hospital Charge Code	8069165
Hospital Revenue Code	975
Min. Negotiated Rate	$355.23
Max. Negotiated Rate	$1,095.75
Rate for Payer: Amerigroup Medicaid	$358.71
Rate for Payer: Cash Price	$1,168.80
Rate for Payer: Cash Price	$1,168.80
Rate for Payer: Iowa Total Care Managed Medicaid	$355.23
Rate for Payer: Medical Associates Commercial	$1,095.75
Rate for Payer: Midlands Choice Commercial	$1,022.70
Rate for Payer: Molina Healthcare Managed Medicaid	$356.97
Rate for Payer: Partners Health Alliance Commercial	$1,095.75
Rate for Payer: United Healthcare Commercial	$685.84
Rate for Payer: Wellmark IA HMO WHPI	$898.20
Rate for Payer: Wellmark IA PPO	$1,056.70

2.2MM X 10MM LOCKING SCREW

Facility

$333.00

Service Code	HCPCS C1713
Hospital Charge Code	8807705
Hospital Revenue Code	278
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: United Healthcare Commercial	$299.70

Know your out-of-pocket cost for care.

All Charges