Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM

Facility

$903.62

Service Code	CPT 13101
Hospital Revenue Code	490
Min. Negotiated Rate	$820.31
Max. Negotiated Rate	$903.62
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

REPAIR FINGER TENDON

Facility

$1,554.00

Service Code	CPT 26418
Hospital Charge Code	4864867
Hospital Revenue Code	450
Min. Negotiated Rate	$699.30
Max. Negotiated Rate	$3,486.38
Rate for Payer: Aetna of IA Commercial	$1,398.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,398.60
Rate for Payer: Aetna of IA Medicare	$885.78
Rate for Payer: Amerigroup Medicaid	$896.35
Rate for Payer: Amerigroup Medicare	$706.29
Rate for Payer: Cash Price	$1,243.20
Rate for Payer: Cash Price	$1,243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,165.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$699.30
Rate for Payer: Iowa Total Care Managed Medicaid	$887.64
Rate for Payer: Medical Associates Commercial	$1,165.50
Rate for Payer: Medical Associates Managed Medicare	$699.30
Rate for Payer: Midlands Choice Commercial	$1,087.80
Rate for Payer: Molina Healthcare Managed Medicaid	$900.70
Rate for Payer: Partners Health Alliance Commercial	$804.20
Rate for Payer: United Healthcare Commercial	$1,398.60
Rate for Payer: United Healthcare Managed Medicare	$916.86
Rate for Payer: Wellmark IA HMO WHPI	$3,164.98
Rate for Payer: Wellmark IA PPO	$3,486.38

REPAIR FINGER TENDON

Facility

$1,554.00

Service Code	CPT 26418
Hospital Charge Code	4864867
Hospital Revenue Code	450
Min. Negotiated Rate	$1,087.80
Max. Negotiated Rate	$1,398.60
Rate for Payer: Aetna of IA Commercial	$1,398.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,398.60
Rate for Payer: Cash Price	$1,243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,165.50
Rate for Payer: Medical Associates Commercial	$1,165.50
Rate for Payer: Midlands Choice Commercial	$1,087.80
Rate for Payer: United Healthcare Commercial	$1,398.60

REPAIR FOREARM TENDON/MUSCLE

Professional

Both

$1,635.00

Service Code	CPT 25270
Hospital Charge Code	7982870
Hospital Revenue Code	981
Min. Negotiated Rate	$491.17
Max. Negotiated Rate	$1,226.25
Rate for Payer: Amerigroup Medicaid	$495.99
Rate for Payer: Cash Price	$1,308.00
Rate for Payer: Cash Price	$1,308.00
Rate for Payer: Iowa Total Care Managed Medicaid	$491.17
Rate for Payer: Medical Associates Commercial	$1,226.25
Rate for Payer: Midlands Choice Commercial	$1,144.50
Rate for Payer: Molina Healthcare Managed Medicaid	$493.58
Rate for Payer: Partners Health Alliance Commercial	$1,226.25
Rate for Payer: United Healthcare Commercial	$744.80
Rate for Payer: Wellmark IA HMO WHPI	$953.60
Rate for Payer: Wellmark IA PPO	$1,121.80

REPAIR FOREARM TENDON/MUSCLE

Facility

$3,062.00

Service Code	CPT 25270
Hospital Charge Code	7982923
Hospital Revenue Code	450
Min. Negotiated Rate	$1,377.90
Max. Negotiated Rate	$4,391.56
Rate for Payer: Aetna of IA Commercial	$2,755.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,755.80
Rate for Payer: Aetna of IA Medicare	$1,745.34
Rate for Payer: Amerigroup Medicaid	$1,766.16
Rate for Payer: Amerigroup Medicare	$1,391.68
Rate for Payer: Cash Price	$2,449.60
Rate for Payer: Cash Price	$2,449.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,296.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,377.90
Rate for Payer: Iowa Total Care Managed Medicaid	$1,749.01
Rate for Payer: Medical Associates Commercial	$2,296.50
Rate for Payer: Medical Associates Managed Medicare	$1,377.90
Rate for Payer: Midlands Choice Commercial	$2,143.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1,774.74
Rate for Payer: Partners Health Alliance Commercial	$1,584.58
Rate for Payer: United Healthcare Commercial	$2,755.80
Rate for Payer: United Healthcare Managed Medicare	$1,806.58
Rate for Payer: Wellmark IA HMO WHPI	$3,986.71
Rate for Payer: Wellmark IA PPO	$4,391.56

REPAIR FOREARM TENDON/MUSCLE

Facility

$3,062.00

Service Code	CPT 25270
Hospital Charge Code	7982923
Hospital Revenue Code	450
Min. Negotiated Rate	$2,143.40
Max. Negotiated Rate	$2,755.80
Rate for Payer: Aetna of IA Commercial	$2,755.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,755.80
Rate for Payer: Cash Price	$2,449.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,296.50
Rate for Payer: Medical Associates Commercial	$2,296.50
Rate for Payer: Midlands Choice Commercial	$2,143.40
Rate for Payer: United Healthcare Commercial	$2,755.80

REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED

Facility

$8,567.57

Service Code	CPT 49507
Hospital Revenue Code	360
Min. Negotiated Rate	$7,777.73
Max. Negotiated Rate	$8,567.57
Rate for Payer: Wellmark IA HMO WHPI	$7,777.73
Rate for Payer: Wellmark IA PPO	$8,567.57

REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS

Facility

$1,127.76

Service Code	CPT 12051
Hospital Revenue Code	490
Min. Negotiated Rate	$1,023.80
Max. Negotiated Rate	$1,127.76
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM

Facility

$1,127.76

Service Code	CPT 12054
Hospital Revenue Code	490
Min. Negotiated Rate	$1,023.80
Max. Negotiated Rate	$1,127.76
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS

Facility

$1,127.76

Service Code	CPT 12041
Hospital Revenue Code	360
Min. Negotiated Rate	$1,023.80
Max. Negotiated Rate	$1,127.76
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS

Facility

$1,127.76

Service Code	CPT 12031
Hospital Revenue Code	360
Min. Negotiated Rate	$1,023.80
Max. Negotiated Rate	$1,127.76
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

REPAIR LIP

Professional

Both

$1,467.00

Service Code	CPT 40650
Hospital Charge Code	7982775
Hospital Revenue Code	981
Min. Negotiated Rate	$282.46
Max. Negotiated Rate	$1,100.25
Rate for Payer: Amerigroup Medicaid	$285.23
Rate for Payer: Cash Price	$1,173.60
Rate for Payer: Cash Price	$1,173.60
Rate for Payer: Iowa Total Care Managed Medicaid	$282.46
Rate for Payer: Medical Associates Commercial	$1,100.25
Rate for Payer: Midlands Choice Commercial	$1,026.90
Rate for Payer: Molina Healthcare Managed Medicaid	$283.84
Rate for Payer: Partners Health Alliance Commercial	$1,100.25
Rate for Payer: United Healthcare Commercial	$696.32
Rate for Payer: Wellmark IA HMO WHPI	$934.40
Rate for Payer: Wellmark IA PPO	$1,099.30

REPAIR LIP

Facility

$1,663.00

Service Code	CPT 40650
Hospital Charge Code	4864950
Hospital Revenue Code	450
Min. Negotiated Rate	$336.78
Max. Negotiated Rate	$1,496.70
Rate for Payer: Aetna of IA Commercial	$1,496.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,496.70
Rate for Payer: Aetna of IA Medicare	$947.91
Rate for Payer: Amerigroup Medicaid	$959.22
Rate for Payer: Amerigroup Medicare	$755.83
Rate for Payer: Cash Price	$1,330.40
Rate for Payer: Cash Price	$1,330.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,247.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$748.35
Rate for Payer: Iowa Total Care Managed Medicaid	$949.91
Rate for Payer: Medical Associates Commercial	$1,247.25
Rate for Payer: Medical Associates Managed Medicare	$748.35
Rate for Payer: Midlands Choice Commercial	$1,164.10
Rate for Payer: Molina Healthcare Managed Medicaid	$963.87
Rate for Payer: Partners Health Alliance Commercial	$860.60
Rate for Payer: United Healthcare Commercial	$1,496.70
Rate for Payer: United Healthcare Managed Medicare	$981.17
Rate for Payer: Wellmark IA HMO WHPI	$336.78
Rate for Payer: Wellmark IA PPO	$370.98

REPAIR LIP

Facility

$1,663.00

Service Code	CPT 40650
Hospital Charge Code	4864950
Hospital Revenue Code	450
Min. Negotiated Rate	$1,164.10
Max. Negotiated Rate	$1,496.70
Rate for Payer: Aetna of IA Commercial	$1,496.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,496.70
Rate for Payer: Cash Price	$1,330.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,247.25
Rate for Payer: Medical Associates Commercial	$1,247.25
Rate for Payer: Midlands Choice Commercial	$1,164.10
Rate for Payer: United Healthcare Commercial	$1,496.70

Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial

Facility

$9,789.05

Service Code	CPT 49596
Min. Negotiated Rate	$8,886.61
Max. Negotiated Rate	$9,789.05
Rate for Payer: Wellmark IA HMO WHPI	$8,886.61
Rate for Payer: Wellmark IA PPO	$9,789.05

REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED

Facility

$9,789.05

Service Code	CPT 49614
Hospital Revenue Code	360
Min. Negotiated Rate	$8,886.61
Max. Negotiated Rate	$9,789.05
Rate for Payer: Wellmark IA HMO WHPI	$8,886.61
Rate for Payer: Wellmark IA PPO	$9,789.05

Facility

$9,789.05

Service Code	CPT 49613
Hospital Revenue Code	360
Min. Negotiated Rate	$8,886.61
Max. Negotiated Rate	$9,789.05
Rate for Payer: Wellmark IA HMO WHPI	$8,886.61
Rate for Payer: Wellmark IA PPO	$9,789.05

REPAIR OF NAIL BED

Facility

$304.00

Service Code	CPT 11760
Hospital Charge Code	4863319
Hospital Revenue Code	450
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$273.60
Rate for Payer: Aetna of IA Commercial	$273.60
Rate for Payer: Aetna of IA Medical Rental Products	$273.60
Rate for Payer: Cash Price	$243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$228.00
Rate for Payer: Medical Associates Commercial	$228.00
Rate for Payer: Midlands Choice Commercial	$212.80
Rate for Payer: United Healthcare Commercial	$273.60

REPAIR OF NAIL BED

Facility

$304.00

Service Code	CPT 11760
Hospital Charge Code	4863319
Hospital Revenue Code	450
Min. Negotiated Rate	$136.80
Max. Negotiated Rate	$487.34
Rate for Payer: Aetna of IA Commercial	$273.60
Rate for Payer: Aetna of IA Medical Rental Products	$273.60
Rate for Payer: Aetna of IA Medicare	$173.28
Rate for Payer: Amerigroup Medicaid	$175.35
Rate for Payer: Amerigroup Medicare	$138.17
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cash Price	$243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$228.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$136.80
Rate for Payer: Iowa Total Care Managed Medicaid	$173.64
Rate for Payer: Medical Associates Commercial	$228.00
Rate for Payer: Medical Associates Managed Medicare	$136.80
Rate for Payer: Midlands Choice Commercial	$212.80
Rate for Payer: Molina Healthcare Managed Medicaid	$176.20
Rate for Payer: Partners Health Alliance Commercial	$157.32
Rate for Payer: United Healthcare Commercial	$273.60
Rate for Payer: United Healthcare Managed Medicare	$179.36
Rate for Payer: Wellmark IA HMO WHPI	$442.42
Rate for Payer: Wellmark IA PPO	$487.34

REPAIR OF NAIL BED SIMPLE

Professional

Both

$624.00

Service Code	CPT 11760
Hospital Charge Code	7982846
Hospital Revenue Code	981
Min. Negotiated Rate	$100.89
Max. Negotiated Rate	$468.00
Rate for Payer: Amerigroup Medicaid	$101.88
Rate for Payer: Cash Price	$499.20
Rate for Payer: Cash Price	$499.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.89
Rate for Payer: Medical Associates Commercial	$468.00
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: Molina Healthcare Managed Medicaid	$101.38
Rate for Payer: Partners Health Alliance Commercial	$468.00
Rate for Payer: United Healthcare Commercial	$293.57
Rate for Payer: Wellmark IA HMO WHPI	$337.90
Rate for Payer: Wellmark IA PPO	$397.50

REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE

Facility

$8,567.57

Service Code	CPT 49520
Hospital Revenue Code	360
Min. Negotiated Rate	$7,777.73
Max. Negotiated Rate	$8,567.57
Rate for Payer: Wellmark IA HMO WHPI	$7,777.73
Rate for Payer: Wellmark IA PPO	$8,567.57

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC

Facility

$14,818.98

Service Code	MSDRG 178
Min. Negotiated Rate	$14,604.21
Max. Negotiated Rate	$14,818.98
Rate for Payer: Amerigroup Medicaid	$14,747.39
Rate for Payer: Iowa Total Care Managed Medicaid	$14,604.21
Rate for Payer: Molina Healthcare Managed Medicaid	$14,818.98

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC

Facility

$16,925.69

Service Code	MSDRG 177
Min. Negotiated Rate	$16,680.38
Max. Negotiated Rate	$16,925.69
Rate for Payer: Amerigroup Medicaid	$16,843.91
Rate for Payer: Iowa Total Care Managed Medicaid	$16,680.38
Rate for Payer: Molina Healthcare Managed Medicaid	$16,925.69

RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC

Facility

$13,661.48

Service Code	MSDRG 179
Min. Negotiated Rate	$13,463.48
Max. Negotiated Rate	$13,661.48
Rate for Payer: Amerigroup Medicaid	$13,595.48
Rate for Payer: Iowa Total Care Managed Medicaid	$13,463.48
Rate for Payer: Molina Healthcare Managed Medicaid	$13,661.48

RESPIRATORY NEOPLASMS WITH CC

Facility

$9,970.53

Service Code	MSDRG 181
Min. Negotiated Rate	$9,826.02
Max. Negotiated Rate	$9,970.53
Rate for Payer: Amerigroup Medicaid	$9,922.36
Rate for Payer: Iowa Total Care Managed Medicaid	$9,826.02
Rate for Payer: Molina Healthcare Managed Medicaid	$9,970.53

Know your out-of-pocket cost for care.

All Charges