Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

TREAT HIP DISLOCATION

Facility

$754.00

Service Code	CPT 27265
Hospital Charge Code	4864782
Hospital Revenue Code	450
Min. Negotiated Rate	$339.30
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: Aetna of IA Medicare	$429.78
Rate for Payer: Amerigroup Medicaid	$434.91
Rate for Payer: Amerigroup Medicare	$342.69
Rate for Payer: Cash Price	$603.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$565.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$339.30
Rate for Payer: Iowa Total Care Managed Medicaid	$430.68
Rate for Payer: Medical Associates Commercial	$565.50
Rate for Payer: Medical Associates Managed Medicare	$339.30
Rate for Payer: Midlands Choice Commercial	$527.80
Rate for Payer: Molina Healthcare Managed Medicaid	$437.02
Rate for Payer: Partners Health Alliance Commercial	$390.19
Rate for Payer: United Healthcare Commercial	$678.60
Rate for Payer: United Healthcare Managed Medicare	$444.86

TREAT HIP DISLOCATION

Facility

$1,393.00

Service Code	CPT 27266
Hospital Charge Code	4864789
Hospital Revenue Code	450
Min. Negotiated Rate	$975.10
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: Cash Price	$1,114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,044.75
Rate for Payer: Medical Associates Commercial	$1,044.75
Rate for Payer: Midlands Choice Commercial	$975.10
Rate for Payer: United Healthcare Commercial	$1,253.70

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 HUMERUS FRACTURE

Facility

$1,256.00

Service Code	CPT 24505
Hospital Charge Code	4864827
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 HUMERUS FRACTURE

Facility

$628.00

Service Code	CPT 24500
Hospital Charge Code	4864825
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 HUMERUS FRACTURE

Facility

$1,256.00

Service Code	CPT 23625
Hospital Charge Code	4864817
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 HUMERUS FRACTURE

Facility

$1,256.00

Service Code	CPT 23605
Hospital Charge Code	4864815
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 HUMERUS FRACTURE

Facility

$628.00

Service Code	CPT 24500
Hospital Charge Code	4864825
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 HUMERUS FRACTURE

Facility

$1,256.00

Service Code	CPT 23625
Hospital Charge Code	4864817
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 HUMERUS FRACTURE

Professional

Both

$1,657.00

Service Code	CPT 24505
Hospital Charge Code	7982809
Hospital Revenue Code	981
Min. Negotiated Rate	$750.69
Max. Negotiated Rate	$1,242.75
Rate for Payer: Cash Price	$1,325.60
Rate for Payer: Cash Price	$1,325.60
Rate for Payer: Medical Associates Commercial	$1,242.75
Rate for Payer: Midlands Choice Commercial	$1,159.90
Rate for Payer: Partners Health Alliance Commercial	$1,242.75
Rate for Payer: United Healthcare Commercial	$750.69

TREAT HUMERUS FRACTURE

Facility

$1,256.00

Service Code	CPT 24505
Hospital Charge Code	4864827
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 HUMERUS FRACTURE

Facility

$1,256.00

Service Code	CPT 23605
Hospital Charge Code	4864815
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 HUMERUS FRACTURE

Professional

Both

$1,254.00

Service Code	CPT 23625
Hospital Charge Code	7982812
Hospital Revenue Code	981
Min. Negotiated Rate	$572.94
Max. Negotiated Rate	$940.50
Rate for Payer: Cash Price	$1,003.20
Rate for Payer: Cash Price	$1,003.20
Rate for Payer: Medical Associates Commercial	$940.50
Rate for Payer: Midlands Choice Commercial	$877.80
Rate for Payer: Partners Health Alliance Commercial	$940.50
Rate for Payer: United Healthcare Commercial	$572.94

TREAT KNEECAP DISLOCATION

Professional

Both

$1,586.00

Service Code	CPT 27562
Hospital Charge Code	7982866
Hospital Revenue Code	981
Min. Negotiated Rate	$732.96
Max. Negotiated Rate	$1,189.50
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Medical Associates Commercial	$1,189.50
Rate for Payer: Midlands Choice Commercial	$1,110.20
Rate for Payer: Partners Health Alliance Commercial	$1,189.50
Rate for Payer: United Healthcare Commercial	$732.96

TREAT KNEECAP DISLOCATION

Facility

$818.00

Service Code	CPT 27562
Hospital Charge Code	7983030
Hospital Revenue Code	450
Min. Negotiated Rate	$572.60
Max. Negotiated Rate	$736.20
Rate for Payer: Aetna of IA Commercial	$736.20
Rate for Payer: Aetna of IA Medical Rental Products	$736.20
Rate for Payer: Cash Price	$654.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$613.50
Rate for Payer: Medical Associates Commercial	$613.50
Rate for Payer: Midlands Choice Commercial	$572.60
Rate for Payer: United Healthcare Commercial	$736.20

TREAT KNEECAP DISLOCATION

Facility

$818.00

Service Code	CPT 27562
Hospital Charge Code	7983030
Hospital Revenue Code	450
Min. Negotiated Rate	$368.10
Max. Negotiated Rate	$736.20
Rate for Payer: Aetna of IA Commercial	$736.20
Rate for Payer: Aetna of IA Medical Rental Products	$736.20
Rate for Payer: Aetna of IA Medicare	$466.26
Rate for Payer: Amerigroup Medicaid	$471.82
Rate for Payer: Amerigroup Medicare	$371.78
Rate for Payer: Cash Price	$654.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$613.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$368.10
Rate for Payer: Iowa Total Care Managed Medicaid	$467.24
Rate for Payer: Medical Associates Commercial	$613.50
Rate for Payer: Medical Associates Managed Medicare	$368.10
Rate for Payer: Midlands Choice Commercial	$572.60
Rate for Payer: Molina Healthcare Managed Medicaid	$474.11
Rate for Payer: Partners Health Alliance Commercial	$423.31
Rate for Payer: United Healthcare Commercial	$736.20
Rate for Payer: United Healthcare Managed Medicare	$482.62

TREAT KNEECAP DISLOCATION

Facility

$879.00

Service Code	CPT 27560
Hospital Charge Code	4864799
Hospital Revenue Code	450
Min. Negotiated Rate	$395.55
Max. Negotiated Rate	$791.10
Rate for Payer: Aetna of IA Commercial	$791.10
Rate for Payer: Aetna of IA Medical Rental Products	$791.10
Rate for Payer: Aetna of IA Medicare	$501.03
Rate for Payer: Amerigroup Medicaid	$507.01
Rate for Payer: Amerigroup Medicare	$399.51
Rate for Payer: Cash Price	$703.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$659.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$395.55
Rate for Payer: Iowa Total Care Managed Medicaid	$502.08
Rate for Payer: Medical Associates Commercial	$659.25
Rate for Payer: Medical Associates Managed Medicare	$395.55
Rate for Payer: Midlands Choice Commercial	$615.30
Rate for Payer: Molina Healthcare Managed Medicaid	$509.47
Rate for Payer: Partners Health Alliance Commercial	$454.88
Rate for Payer: United Healthcare Commercial	$791.10
Rate for Payer: United Healthcare Managed Medicare	$518.61

TREAT KNEECAP DISLOCATION

Professional

Both

$1,194.00

Service Code	CPT 27560
Hospital Charge Code	7982794
Hospital Revenue Code	981
Min. Negotiated Rate	$561.89
Max. Negotiated Rate	$895.50
Rate for Payer: Cash Price	$955.20
Rate for Payer: Cash Price	$955.20
Rate for Payer: Medical Associates Commercial	$895.50
Rate for Payer: Midlands Choice Commercial	$835.80
Rate for Payer: Partners Health Alliance Commercial	$895.50
Rate for Payer: United Healthcare Commercial	$561.89

TREAT KNEECAP DISLOCATION

Facility

$879.00

Service Code	CPT 27560
Hospital Charge Code	4864799
Hospital Revenue Code	450
Min. Negotiated Rate	$615.30
Max. Negotiated Rate	$791.10
Rate for Payer: Aetna of IA Commercial	$791.10
Rate for Payer: Aetna of IA Medical Rental Products	$791.10
Rate for Payer: Cash Price	$703.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$659.25
Rate for Payer: Medical Associates Commercial	$659.25
Rate for Payer: Midlands Choice Commercial	$615.30
Rate for Payer: United Healthcare Commercial	$791.10

TREAT KNEECAP FRACTURE

Facility

$879.00

Service Code	CPT 27520
Hospital Charge Code	7983026
Hospital Revenue Code	450
Min. Negotiated Rate	$615.30
Max. Negotiated Rate	$791.10
Rate for Payer: Aetna of IA Commercial	$791.10
Rate for Payer: Aetna of IA Medical Rental Products	$791.10
Rate for Payer: Cash Price	$703.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$659.25
Rate for Payer: Medical Associates Commercial	$659.25
Rate for Payer: Midlands Choice Commercial	$615.30
Rate for Payer: United Healthcare Commercial	$791.10

TREAT KNEECAP FRACTURE

Facility

$879.00

Service Code	CPT 27520
Hospital Charge Code	7983026
Hospital Revenue Code	450
Min. Negotiated Rate	$395.55
Max. Negotiated Rate	$791.10
Rate for Payer: Aetna of IA Commercial	$791.10
Rate for Payer: Aetna of IA Medical Rental Products	$791.10
Rate for Payer: Aetna of IA Medicare	$501.03
Rate for Payer: Amerigroup Medicaid	$507.01
Rate for Payer: Amerigroup Medicare	$399.51
Rate for Payer: Cash Price	$703.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$659.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$395.55
Rate for Payer: Iowa Total Care Managed Medicaid	$502.08
Rate for Payer: Medical Associates Commercial	$659.25
Rate for Payer: Medical Associates Managed Medicare	$395.55
Rate for Payer: Midlands Choice Commercial	$615.30
Rate for Payer: Molina Healthcare Managed Medicaid	$509.47
Rate for Payer: Partners Health Alliance Commercial	$454.88
Rate for Payer: United Healthcare Commercial	$791.10
Rate for Payer: United Healthcare Managed Medicare	$518.61

TREAT KNEE DISLOCATION

Professional

Both

$1,493.00

Service Code	CPT 27550
Hospital Charge Code	7982795
Hospital Revenue Code	981
Min. Negotiated Rate	$787.42
Max. Negotiated Rate	$1,119.75
Rate for Payer: Cash Price	$1,194.40
Rate for Payer: Cash Price	$1,194.40
Rate for Payer: Medical Associates Commercial	$1,119.75
Rate for Payer: Midlands Choice Commercial	$1,045.10
Rate for Payer: Partners Health Alliance Commercial	$1,119.75
Rate for Payer: United Healthcare Commercial	$787.42

TREAT KNEE DISLOCATION

Facility

$754.00

Service Code	CPT 27550
Hospital Charge Code	4864797
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 KNEE DISLOCATION

Facility

$754.00

Service Code	CPT 27550
Hospital Charge Code	4864797
Hospital Revenue Code	450
Min. Negotiated Rate	$339.30
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: Aetna of IA Medicare	$429.78
Rate for Payer: Amerigroup Medicaid	$434.91
Rate for Payer: Amerigroup Medicare	$342.69
Rate for Payer: Cash Price	$603.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$565.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$339.30
Rate for Payer: Iowa Total Care Managed Medicaid	$430.68
Rate for Payer: Medical Associates Commercial	$565.50
Rate for Payer: Medical Associates Managed Medicare	$339.30
Rate for Payer: Midlands Choice Commercial	$527.80
Rate for Payer: Molina Healthcare Managed Medicaid	$437.02
Rate for Payer: Partners Health Alliance Commercial	$390.19
Rate for Payer: United Healthcare Commercial	$678.60
Rate for Payer: United Healthcare Managed Medicare	$444.86

TREAT KNUCKLE DISLOCATION

Facility

$686.00

Service Code	CPT 26700
Hospital Charge Code	4862814
Hospital Revenue Code	450
Min. Negotiated Rate	$480.20
Max. Negotiated Rate	$617.40
Rate for Payer: Aetna of IA Commercial	$617.40
Rate for Payer: Aetna of IA Medical Rental Products	$617.40
Rate for Payer: Cash Price	$548.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$514.50
Rate for Payer: Medical Associates Commercial	$514.50
Rate for Payer: Midlands Choice Commercial	$480.20
Rate for Payer: United Healthcare Commercial	$617.40

Know your out-of-pocket cost for care.

All Charges