Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

TREAT FINGER FRACTURE EACH

Facility

$748.00

Service Code	CPT 26725
Hospital Charge Code	4863316
Hospital Revenue Code	450
Min. Negotiated Rate	$523.60
Max. Negotiated Rate	$673.20
Rate for Payer: Aetna of IA Commercial	$673.20
Rate for Payer: Aetna of IA Medical Rental Products	$673.20
Rate for Payer: Cash Price	$598.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$561.00
Rate for Payer: Medical Associates Commercial	$561.00
Rate for Payer: Midlands Choice Commercial	$523.60
Rate for Payer: United Healthcare Commercial	$673.20

TREAT FOOT BONE LESION

Facility

$4,699.00

Service Code	CPT 28005
Hospital Charge Code	7982939
Hospital Revenue Code	450
Min. Negotiated Rate	$3,289.30
Max. Negotiated Rate	$4,229.10
Rate for Payer: Aetna of IA Commercial	$4,229.10
Rate for Payer: Aetna of IA Medical Rental Products	$4,229.10
Rate for Payer: Cash Price	$3,759.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,524.25
Rate for Payer: Medical Associates Commercial	$3,524.25
Rate for Payer: Midlands Choice Commercial	$3,289.30
Rate for Payer: United Healthcare Commercial	$4,229.10

TREAT FOOT BONE LESION

Facility

$4,699.00

Service Code	CPT 28005
Hospital Charge Code	7982939
Hospital Revenue Code	450
Min. Negotiated Rate	$2,114.55
Max. Negotiated Rate	$4,229.10
Rate for Payer: Aetna of IA Commercial	$4,229.10
Rate for Payer: Aetna of IA Medical Rental Products	$4,229.10
Rate for Payer: Aetna of IA Medicare	$2,678.43
Rate for Payer: Amerigroup Medicaid	$2,710.38
Rate for Payer: Amerigroup Medicare	$2,135.70
Rate for Payer: Cash Price	$3,759.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,524.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,114.55
Rate for Payer: Iowa Total Care Managed Medicaid	$2,684.07
Rate for Payer: Medical Associates Commercial	$3,524.25
Rate for Payer: Medical Associates Managed Medicare	$2,114.55
Rate for Payer: Midlands Choice Commercial	$3,289.30
Rate for Payer: Molina Healthcare Managed Medicaid	$2,723.54
Rate for Payer: Partners Health Alliance Commercial	$2,431.73
Rate for Payer: United Healthcare Commercial	$4,229.10
Rate for Payer: United Healthcare Managed Medicare	$2,772.41

TREAT FRACTURE OF RADIUS

Facility

$1,256.00

Service Code	CPT 25505
Hospital Charge Code	7983025
Hospital Revenue Code	450
Min. Negotiated Rate	$565.20
Max. Negotiated Rate	$1,130.40
Rate for Payer: Aetna of IA Commercial	$1,130.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,130.40
Rate for Payer: Aetna of IA Medicare	$715.92
Rate for Payer: Amerigroup Medicaid	$724.46
Rate for Payer: Amerigroup Medicare	$570.85
Rate for Payer: Cash Price	$1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$942.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$565.20
Rate for Payer: Iowa Total Care Managed Medicaid	$717.43
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Medical Associates Managed Medicare	$565.20
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: Molina Healthcare Managed Medicaid	$727.98
Rate for Payer: Partners Health Alliance Commercial	$649.98
Rate for Payer: United Healthcare Commercial	$1,130.40
Rate for Payer: United Healthcare Managed Medicare	$741.04

TREAT FRACTURE OF RADIUS

Facility

$1,256.00

Service Code	CPT 25505
Hospital Charge Code	7983025
Hospital Revenue Code	450
Min. Negotiated Rate	$879.20
Max. Negotiated Rate	$1,130.40
Rate for Payer: Aetna of IA Commercial	$1,130.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,130.40
Rate for Payer: Cash Price	$1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$942.00
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: United Healthcare Commercial	$1,130.40

TREAT FRACTURE OF RADIUS

Professional

Both

$1,409.00

Service Code	CPT 25505
Hospital Charge Code	7982869
Hospital Revenue Code	981
Min. Negotiated Rate	$758.86
Max. Negotiated Rate	$1,056.75
Rate for Payer: Cash Price	$1,127.20
Rate for Payer: Cash Price	$1,127.20
Rate for Payer: Medical Associates Commercial	$1,056.75
Rate for Payer: Midlands Choice Commercial	$986.30
Rate for Payer: Partners Health Alliance Commercial	$1,056.75
Rate for Payer: United Healthcare Commercial	$758.86

TREAT FRACTURE OF ULNA

Facility

$628.00

Service Code	CPT 25535
Hospital Charge Code	7983020
Hospital Revenue Code	450
Min. Negotiated Rate	$439.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: United Healthcare Commercial	$565.20

TREAT FRACTURE OF ULNA

Facility

$628.00

Service Code	CPT 25535
Hospital Charge Code	7983020
Hospital Revenue Code	450
Min. Negotiated Rate	$282.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Aetna of IA Medicare	$357.96
Rate for Payer: Amerigroup Medicaid	$362.23
Rate for Payer: Amerigroup Medicare	$285.43
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$282.60
Rate for Payer: Iowa Total Care Managed Medicaid	$358.71
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Medical Associates Managed Medicare	$282.60
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: Molina Healthcare Managed Medicaid	$363.99
Rate for Payer: Partners Health Alliance Commercial	$324.99
Rate for Payer: United Healthcare Commercial	$565.20
Rate for Payer: United Healthcare Managed Medicare	$370.52

TREAT FRACTURE RADIUS ULNA

Facility

$628.00

Service Code	CPT 25560
Hospital Charge Code	4864847
Hospital Revenue Code	450
Min. Negotiated Rate	$439.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: United Healthcare Commercial	$565.20

TREAT FRACTURE RADIUS ULNA

Facility

$1,256.00

Service Code	CPT 25565
Hospital Charge Code	4864848
Hospital Revenue Code	761
Min. Negotiated Rate	$565.20
Max. Negotiated Rate	$1,130.40
Rate for Payer: Aetna of IA Commercial	$1,130.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,130.40
Rate for Payer: Aetna of IA Medicare	$715.92
Rate for Payer: Amerigroup Medicaid	$724.46
Rate for Payer: Amerigroup Medicare	$570.85
Rate for Payer: Cash Price	$1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$942.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$565.20
Rate for Payer: Iowa Total Care Managed Medicaid	$717.43
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Medical Associates Managed Medicare	$565.20
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: Molina Healthcare Managed Medicaid	$727.98
Rate for Payer: Partners Health Alliance Commercial	$649.98
Rate for Payer: United Healthcare Commercial	$1,130.40
Rate for Payer: United Healthcare Managed Medicare	$741.04

TREAT FRACTURE RADIUS ULNA

Professional

Both

$920.00

Service Code	CPT 25560
Hospital Charge Code	7982807
Hospital Revenue Code	981
Min. Negotiated Rate	$427.36
Max. Negotiated Rate	$690.00
Rate for Payer: Cash Price	$736.00
Rate for Payer: Cash Price	$736.00
Rate for Payer: Medical Associates Commercial	$690.00
Rate for Payer: Midlands Choice Commercial	$644.00
Rate for Payer: Partners Health Alliance Commercial	$690.00
Rate for Payer: United Healthcare Commercial	$427.36

TREAT FRACTURE RADIUS ULNA

Facility

$1,256.00

Service Code	CPT 25565
Hospital Charge Code	4864848
Hospital Revenue Code	761
Min. Negotiated Rate	$879.20
Max. Negotiated Rate	$1,130.40
Rate for Payer: Aetna of IA Commercial	$1,130.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,130.40
Rate for Payer: Cash Price	$1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$942.00
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: United Healthcare Commercial	$1,130.40

TREAT FRACTURE RADIUS ULNA

Facility

$628.00

Service Code	CPT 25560
Hospital Charge Code	4864847
Hospital Revenue Code	450
Min. Negotiated Rate	$282.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Aetna of IA Medicare	$357.96
Rate for Payer: Amerigroup Medicaid	$362.23
Rate for Payer: Amerigroup Medicare	$285.43
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$282.60
Rate for Payer: Iowa Total Care Managed Medicaid	$358.71
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Medical Associates Managed Medicare	$282.60
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: Molina Healthcare Managed Medicaid	$363.99
Rate for Payer: Partners Health Alliance Commercial	$324.99
Rate for Payer: United Healthcare Commercial	$565.20
Rate for Payer: United Healthcare Managed Medicare	$370.52

TREAT FRACTURE RADIUS/ULNA

Facility

$1,256.00

Service Code	CPT 25605
Hospital Charge Code	4864851
Hospital Revenue Code	450
Min. Negotiated Rate	$879.20
Max. Negotiated Rate	$1,130.40
Rate for Payer: Aetna of IA Commercial	$1,130.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,130.40
Rate for Payer: Cash Price	$1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$942.00
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: United Healthcare Commercial	$1,130.40

TREAT FRACTURE RADIUS/ULNA

Professional

Both

$1,805.00

Service Code	CPT 25605
Hospital Charge Code	7982805
Hospital Revenue Code	981
Min. Negotiated Rate	$814.96
Max. Negotiated Rate	$1,353.75
Rate for Payer: Cash Price	$1,444.00
Rate for Payer: Cash Price	$1,444.00
Rate for Payer: Medical Associates Commercial	$1,353.75
Rate for Payer: Midlands Choice Commercial	$1,263.50
Rate for Payer: Partners Health Alliance Commercial	$1,353.75
Rate for Payer: United Healthcare Commercial	$814.96

TREAT FRACTURE RADIUS/ULNA

Facility

$628.00

Service Code	CPT 25600
Hospital Charge Code	4864850
Hospital Revenue Code	450
Min. Negotiated Rate	$282.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Aetna of IA Medicare	$357.96
Rate for Payer: Amerigroup Medicaid	$362.23
Rate for Payer: Amerigroup Medicare	$285.43
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$282.60
Rate for Payer: Iowa Total Care Managed Medicaid	$358.71
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Medical Associates Managed Medicare	$282.60
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: Molina Healthcare Managed Medicaid	$363.99
Rate for Payer: Partners Health Alliance Commercial	$324.99
Rate for Payer: United Healthcare Commercial	$565.20
Rate for Payer: United Healthcare Managed Medicare	$370.52

TREAT FRACTURE RADIUS/ULNA

Facility

$628.00

Service Code	CPT 25600
Hospital Charge Code	4864850
Hospital Revenue Code	450
Min. Negotiated Rate	$439.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: United Healthcare Commercial	$565.20

TREAT FRACTURE RADIUS/ULNA

Facility

$1,256.00

Service Code	CPT 25605
Hospital Charge Code	4864851
Hospital Revenue Code	450
Min. Negotiated Rate	$565.20
Max. Negotiated Rate	$1,130.40
Rate for Payer: Aetna of IA Commercial	$1,130.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,130.40
Rate for Payer: Aetna of IA Medicare	$715.92
Rate for Payer: Amerigroup Medicaid	$724.46
Rate for Payer: Amerigroup Medicare	$570.85
Rate for Payer: Cash Price	$1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$942.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$565.20
Rate for Payer: Iowa Total Care Managed Medicaid	$717.43
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Medical Associates Managed Medicare	$565.20
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: Molina Healthcare Managed Medicaid	$727.98
Rate for Payer: Partners Health Alliance Commercial	$649.98
Rate for Payer: United Healthcare Commercial	$1,130.40
Rate for Payer: United Healthcare Managed Medicare	$741.04

TREAT FRACTURE RADIUS/ULNA

Professional

Both

$1,087.00

Service Code	CPT 25600
Hospital Charge Code	7982806
Hospital Revenue Code	981
Min. Negotiated Rate	$498.50
Max. Negotiated Rate	$815.25
Rate for Payer: Cash Price	$869.60
Rate for Payer: Cash Price	$869.60
Rate for Payer: Medical Associates Commercial	$815.25
Rate for Payer: Midlands Choice Commercial	$760.90
Rate for Payer: Partners Health Alliance Commercial	$815.25
Rate for Payer: United Healthcare Commercial	$498.50

TREAT HAND DISLOCATION

Facility

$3,510.00

Service Code	CPT 26686
Hospital Charge Code	7982927
Hospital Revenue Code	450
Min. Negotiated Rate	$1,579.50
Max. Negotiated Rate	$3,159.00
Rate for Payer: Aetna of IA Commercial	$3,159.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,159.00
Rate for Payer: Aetna of IA Medicare	$2,000.70
Rate for Payer: Amerigroup Medicaid	$2,024.57
Rate for Payer: Amerigroup Medicare	$1,595.30
Rate for Payer: Cash Price	$2,808.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,632.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,579.50
Rate for Payer: Iowa Total Care Managed Medicaid	$2,004.91
Rate for Payer: Medical Associates Commercial	$2,632.50
Rate for Payer: Medical Associates Managed Medicare	$1,579.50
Rate for Payer: Midlands Choice Commercial	$2,457.00
Rate for Payer: Molina Healthcare Managed Medicaid	$2,034.40
Rate for Payer: Partners Health Alliance Commercial	$1,816.42
Rate for Payer: United Healthcare Commercial	$3,159.00
Rate for Payer: United Healthcare Managed Medicare	$2,070.90

TREAT HAND DISLOCATION

Facility

$3,510.00

Service Code	CPT 26686
Hospital Charge Code	7982927
Hospital Revenue Code	450
Min. Negotiated Rate	$2,457.00
Max. Negotiated Rate	$3,159.00
Rate for Payer: Aetna of IA Commercial	$3,159.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,159.00
Rate for Payer: Cash Price	$2,808.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,632.50
Rate for Payer: Medical Associates Commercial	$2,632.50
Rate for Payer: Midlands Choice Commercial	$2,457.00
Rate for Payer: United Healthcare Commercial	$3,159.00

TREAT HAND DISLOCATION

Professional

Both

$2,085.00

Service Code	CPT 26686
Hospital Charge Code	7982867
Hospital Revenue Code	981
Min. Negotiated Rate	$941.14
Max. Negotiated Rate	$1,563.75
Rate for Payer: Cash Price	$1,668.00
Rate for Payer: Cash Price	$1,668.00
Rate for Payer: Medical Associates Commercial	$1,563.75
Rate for Payer: Midlands Choice Commercial	$1,459.50
Rate for Payer: Partners Health Alliance Commercial	$1,563.75
Rate for Payer: United Healthcare Commercial	$941.14

TREAT HIP DISLOCATION

Facility

$1,393.00

Service Code	CPT 27266
Hospital Charge Code	4864789
Hospital Revenue Code	450
Min. Negotiated Rate	$626.85
Max. Negotiated Rate	$1,253.70
Rate for Payer: Aetna of IA Commercial	$1,253.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,253.70
Rate for Payer: Aetna of IA Medicare	$794.01
Rate for Payer: Amerigroup Medicaid	$803.48
Rate for Payer: Amerigroup Medicare	$633.12
Rate for Payer: Cash Price	$1,114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,044.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$626.85
Rate for Payer: Iowa Total Care Managed Medicaid	$795.68
Rate for Payer: Medical Associates Commercial	$1,044.75
Rate for Payer: Medical Associates Managed Medicare	$626.85
Rate for Payer: Midlands Choice Commercial	$975.10
Rate for Payer: Molina Healthcare Managed Medicaid	$807.38
Rate for Payer: Partners Health Alliance Commercial	$720.88
Rate for Payer: United Healthcare Commercial	$1,253.70
Rate for Payer: United Healthcare Managed Medicare	$821.87

TREAT HIP DISLOCATION

Facility

$754.00

Service Code	CPT 27265
Hospital Charge Code	4864782
Hospital Revenue Code	450
Min. Negotiated Rate	$527.80
Max. Negotiated Rate	$678.60
Rate for Payer: Aetna of IA Commercial	$678.60
Rate for Payer: Aetna of IA Medical Rental Products	$678.60
Rate for Payer: Cash Price	$603.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$565.50
Rate for Payer: Medical Associates Commercial	$565.50
Rate for Payer: Midlands Choice Commercial	$527.80
Rate for Payer: United Healthcare Commercial	$678.60

TREAT HIP DISLOCATION

Facility

$864.00

Service Code	CPT 27250
Hospital Charge Code	4863441
Hospital Revenue Code	450
Min. Negotiated Rate	$604.80
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of IA Commercial	$777.60
Rate for Payer: Aetna of IA Medical Rental Products	$777.60
Rate for Payer: Cash Price	$691.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$648.00
Rate for Payer: Medical Associates Commercial	$648.00
Rate for Payer: Midlands Choice Commercial	$604.80
Rate for Payer: United Healthcare Commercial	$777.60

Know your out-of-pocket cost for care.

All Charges