Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

TREAT KNUCKLE DISLOCATION

Facility

$686.00

Service Code	CPT 26700
Hospital Charge Code	4862814
Hospital Revenue Code	450
Min. Negotiated Rate	$308.70
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: Aetna of IA Medicare	$391.02
Rate for Payer: Amerigroup Medicaid	$395.68
Rate for Payer: Amerigroup Medicare	$311.79
Rate for Payer: Cash Price	$548.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$514.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$308.70
Rate for Payer: Iowa Total Care Managed Medicaid	$391.84
Rate for Payer: Medical Associates Commercial	$514.50
Rate for Payer: Medical Associates Managed Medicare	$308.70
Rate for Payer: Midlands Choice Commercial	$480.20
Rate for Payer: Molina Healthcare Managed Medicaid	$397.61
Rate for Payer: Partners Health Alliance Commercial	$355.00
Rate for Payer: United Healthcare Commercial	$617.40
Rate for Payer: United Healthcare Managed Medicare	$404.74

TREAT KNUCKLE DISLOCATION

Professional

Both

$1,071.00

Service Code	CPT 26700
Hospital Charge Code	7982801
Hospital Revenue Code	981
Min. Negotiated Rate	$500.37
Max. Negotiated Rate	$803.25
Rate for Payer: Cash Price	$856.80
Rate for Payer: Cash Price	$856.80
Rate for Payer: Medical Associates Commercial	$803.25
Rate for Payer: Midlands Choice Commercial	$749.70
Rate for Payer: Partners Health Alliance Commercial	$803.25
Rate for Payer: United Healthcare Commercial	$500.37

TREAT LOWER LEG FRACTURE

Facility

$1,256.00

Service Code	CPT 27824
Hospital Charge Code	7983034
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 LOWER LEG FRACTURE

Facility

$1,256.00

Service Code	CPT 27824
Hospital Charge Code	7983034
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

TREATMEN CLOSED ELBOW DISLOCATION W/O ANESTH

Professional

Both

$1,289.00

Service Code	CPT 24600
Hospital Charge Code	8822635
Hospital Revenue Code	981
Min. Negotiated Rate	$558.06
Max. Negotiated Rate	$966.75
Rate for Payer: Cash Price	$1,031.20
Rate for Payer: Cash Price	$1,031.20
Rate for Payer: Medical Associates Commercial	$966.75
Rate for Payer: Midlands Choice Commercial	$902.30
Rate for Payer: Partners Health Alliance Commercial	$966.75
Rate for Payer: United Healthcare Commercial	$558.06

TREATMENT OF ANKLE FRACTURE

Facility

$502.00

Service Code	CPT 27786
Hospital Charge Code	4864808
Hospital Revenue Code	450
Min. Negotiated Rate	$225.90
Max. Negotiated Rate	$451.80
Rate for Payer: Aetna of IA Commercial	$451.80
Rate for Payer: Aetna of IA Medical Rental Products	$451.80
Rate for Payer: Aetna of IA Medicare	$286.14
Rate for Payer: Amerigroup Medicaid	$289.55
Rate for Payer: Amerigroup Medicare	$228.16
Rate for Payer: Cash Price	$401.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$376.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$225.90
Rate for Payer: Iowa Total Care Managed Medicaid	$286.74
Rate for Payer: Medical Associates Commercial	$376.50
Rate for Payer: Medical Associates Managed Medicare	$225.90
Rate for Payer: Midlands Choice Commercial	$351.40
Rate for Payer: Molina Healthcare Managed Medicaid	$290.96
Rate for Payer: Partners Health Alliance Commercial	$259.79
Rate for Payer: United Healthcare Commercial	$451.80
Rate for Payer: United Healthcare Managed Medicare	$296.18

TREATMENT OF ANKLE FRACTURE

Facility

$1,256.00

Service Code	CPT 27818
Hospital Charge Code	4864824
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

TREATMENT OF ANKLE FRACTURE

Facility

$502.00

Service Code	CPT 27786
Hospital Charge Code	4864808
Hospital Revenue Code	450
Min. Negotiated Rate	$351.40
Max. Negotiated Rate	$451.80
Rate for Payer: Aetna of IA Commercial	$451.80
Rate for Payer: Aetna of IA Medical Rental Products	$451.80
Rate for Payer: Cash Price	$401.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$376.50
Rate for Payer: Medical Associates Commercial	$376.50
Rate for Payer: Midlands Choice Commercial	$351.40
Rate for Payer: United Healthcare Commercial	$451.80

TREATMENT OF ANKLE FRACTURE

Facility

$1,256.00

Service Code	CPT 27788
Hospital Charge Code	4864811
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

TREATMENT OF ANKLE FRACTURE

Facility

$1,256.00

Service Code	CPT 27818
Hospital Charge Code	4864824
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

TREATMENT OF ANKLE FRACTURE

Facility

$1,256.00

Service Code	CPT 27788
Hospital Charge Code	4864811
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

TREATMENT OF BLADDER LESION

Facility

$996.00

Service Code	CPT 51720
Hospital Charge Code	7983039
Hospital Revenue Code	450
Min. Negotiated Rate	$448.20
Max. Negotiated Rate	$896.40
Rate for Payer: Aetna of IA Commercial	$896.40
Rate for Payer: Aetna of IA Medical Rental Products	$896.40
Rate for Payer: Aetna of IA Medicare	$567.72
Rate for Payer: Amerigroup Medicaid	$574.49
Rate for Payer: Amerigroup Medicare	$452.68
Rate for Payer: Cash Price	$796.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$747.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$448.20
Rate for Payer: Iowa Total Care Managed Medicaid	$568.92
Rate for Payer: Medical Associates Commercial	$747.00
Rate for Payer: Medical Associates Managed Medicare	$448.20
Rate for Payer: Midlands Choice Commercial	$697.20
Rate for Payer: Molina Healthcare Managed Medicaid	$577.28
Rate for Payer: Partners Health Alliance Commercial	$515.43
Rate for Payer: United Healthcare Commercial	$896.40
Rate for Payer: United Healthcare Managed Medicare	$587.64

TREATMENT OF BLADDER LESION

Facility

$996.00

Service Code	CPT 51720
Hospital Charge Code	7983039
Hospital Revenue Code	450
Min. Negotiated Rate	$697.20
Max. Negotiated Rate	$896.40
Rate for Payer: Aetna of IA Commercial	$896.40
Rate for Payer: Aetna of IA Medical Rental Products	$896.40
Rate for Payer: Cash Price	$796.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$747.00
Rate for Payer: Medical Associates Commercial	$747.00
Rate for Payer: Midlands Choice Commercial	$697.20
Rate for Payer: United Healthcare Commercial	$896.40

TREATMENT OF PENIS LESION

Facility

$2,213.00

Service Code	CPT 54115
Hospital Charge Code	7982920
Hospital Revenue Code	450
Min. Negotiated Rate	$995.85
Max. Negotiated Rate	$1,991.70
Rate for Payer: Aetna of IA Commercial	$1,991.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,991.70
Rate for Payer: Aetna of IA Medicare	$1,261.41
Rate for Payer: Amerigroup Medicaid	$1,276.46
Rate for Payer: Amerigroup Medicare	$1,005.81
Rate for Payer: Cash Price	$1,770.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,659.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$995.85
Rate for Payer: Iowa Total Care Managed Medicaid	$1,264.07
Rate for Payer: Medical Associates Commercial	$1,659.75
Rate for Payer: Medical Associates Managed Medicare	$995.85
Rate for Payer: Midlands Choice Commercial	$1,549.10
Rate for Payer: Molina Healthcare Managed Medicaid	$1,282.65
Rate for Payer: Partners Health Alliance Commercial	$1,145.23
Rate for Payer: United Healthcare Commercial	$1,991.70
Rate for Payer: United Healthcare Managed Medicare	$1,305.67

TREATMENT OF PENIS LESION

Facility

$2,213.00

Service Code	CPT 54115
Hospital Charge Code	7982920
Hospital Revenue Code	450
Min. Negotiated Rate	$1,549.10
Max. Negotiated Rate	$1,991.70
Rate for Payer: Aetna of IA Commercial	$1,991.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,991.70
Rate for Payer: Cash Price	$1,770.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,659.75
Rate for Payer: Medical Associates Commercial	$1,659.75
Rate for Payer: Midlands Choice Commercial	$1,549.10
Rate for Payer: United Healthcare Commercial	$1,991.70

TREATMENT OF TOE FRACTURE

Facility

$1,339.00

Service Code	CPT 28515
Hospital Charge Code	4864863
Hospital Revenue Code	450
Min. Negotiated Rate	$937.30
Max. Negotiated Rate	$1,205.10
Rate for Payer: Aetna of IA Commercial	$1,205.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,205.10
Rate for Payer: Cash Price	$1,071.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,004.25
Rate for Payer: Medical Associates Commercial	$1,004.25
Rate for Payer: Midlands Choice Commercial	$937.30
Rate for Payer: United Healthcare Commercial	$1,205.10

TREATMENT OF TOE FRACTURE

Facility

$1,339.00

Service Code	CPT 28515
Hospital Charge Code	4864863
Hospital Revenue Code	450
Min. Negotiated Rate	$602.55
Max. Negotiated Rate	$1,205.10
Rate for Payer: Aetna of IA Commercial	$1,205.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,205.10
Rate for Payer: Aetna of IA Medicare	$763.23
Rate for Payer: Amerigroup Medicaid	$772.34
Rate for Payer: Amerigroup Medicare	$608.58
Rate for Payer: Cash Price	$1,071.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,004.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$602.55
Rate for Payer: Iowa Total Care Managed Medicaid	$764.84
Rate for Payer: Medical Associates Commercial	$1,004.25
Rate for Payer: Medical Associates Managed Medicare	$602.55
Rate for Payer: Midlands Choice Commercial	$937.30
Rate for Payer: Molina Healthcare Managed Medicaid	$776.08
Rate for Payer: Partners Health Alliance Commercial	$692.93
Rate for Payer: United Healthcare Commercial	$1,205.10
Rate for Payer: United Healthcare Managed Medicare	$790.01

TREAT METACARPAL FRACTURE

Facility

$628.00

Service Code	CPT 26600
Hospital Charge Code	4864869
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 METACARPAL FRACTURE

Facility

$628.00

Service Code	CPT 26600
Hospital Charge Code	4864869
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 METACARPAL FRACTURE

Professional

Both

$858.00

Service Code	CPT 26600
Hospital Charge Code	7982803
Hospital Revenue Code	981
Min. Negotiated Rate	$445.74
Max. Negotiated Rate	$643.50
Rate for Payer: Cash Price	$686.40
Rate for Payer: Cash Price	$686.40
Rate for Payer: Medical Associates Commercial	$643.50
Rate for Payer: Midlands Choice Commercial	$600.60
Rate for Payer: Partners Health Alliance Commercial	$643.50
Rate for Payer: United Healthcare Commercial	$445.74

TREAT SHOULDER DISLOCATION

Professional

Both

$1,040.00

Service Code	CPT 23650
Hospital Charge Code	7982811
Hospital Revenue Code	981
Min. Negotiated Rate	$481.06
Max. Negotiated Rate	$780.00
Rate for Payer: Cash Price	$832.00
Rate for Payer: Cash Price	$832.00
Rate for Payer: Medical Associates Commercial	$780.00
Rate for Payer: Midlands Choice Commercial	$728.00
Rate for Payer: Partners Health Alliance Commercial	$780.00
Rate for Payer: United Healthcare Commercial	$481.06

TREAT SHOULDER DISLOCATION

Facility

$686.00

Service Code	CPT 23650
Hospital Charge Code	4864819
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

TREAT SHOULDER DISLOCATION

Facility

$686.00

Service Code	CPT 23650
Hospital Charge Code	4864819
Hospital Revenue Code	450
Min. Negotiated Rate	$308.70
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: Aetna of IA Medicare	$391.02
Rate for Payer: Amerigroup Medicaid	$395.68
Rate for Payer: Amerigroup Medicare	$311.79
Rate for Payer: Cash Price	$548.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$514.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$308.70
Rate for Payer: Iowa Total Care Managed Medicaid	$391.84
Rate for Payer: Medical Associates Commercial	$514.50
Rate for Payer: Medical Associates Managed Medicare	$308.70
Rate for Payer: Midlands Choice Commercial	$480.20
Rate for Payer: Molina Healthcare Managed Medicaid	$397.61
Rate for Payer: Partners Health Alliance Commercial	$355.00
Rate for Payer: United Healthcare Commercial	$617.40
Rate for Payer: United Healthcare Managed Medicare	$404.74

TREAT SHOULDER DISLOCATION

Facility

$1,169.00

Service Code	CPT 23655
Hospital Charge Code	4864821
Hospital Revenue Code	450
Min. Negotiated Rate	$818.30
Max. Negotiated Rate	$1,052.10
Rate for Payer: Aetna of IA Commercial	$1,052.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,052.10
Rate for Payer: Cash Price	$935.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$876.75
Rate for Payer: Medical Associates Commercial	$876.75
Rate for Payer: Midlands Choice Commercial	$818.30
Rate for Payer: United Healthcare Commercial	$1,052.10

TREAT SHOULDER DISLOCATION

Facility

$1,169.00

Service Code	CPT 23655
Hospital Charge Code	4864821
Hospital Revenue Code	450
Min. Negotiated Rate	$526.05
Max. Negotiated Rate	$1,052.10
Rate for Payer: Aetna of IA Commercial	$1,052.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,052.10
Rate for Payer: Aetna of IA Medicare	$666.33
Rate for Payer: Amerigroup Medicaid	$674.28
Rate for Payer: Amerigroup Medicare	$531.31
Rate for Payer: Cash Price	$935.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$876.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$526.05
Rate for Payer: Iowa Total Care Managed Medicaid	$667.73
Rate for Payer: Medical Associates Commercial	$876.75
Rate for Payer: Medical Associates Managed Medicare	$526.05
Rate for Payer: Midlands Choice Commercial	$818.30
Rate for Payer: Molina Healthcare Managed Medicaid	$677.55
Rate for Payer: Partners Health Alliance Commercial	$604.96
Rate for Payer: United Healthcare Commercial	$1,052.10
Rate for Payer: United Healthcare Managed Medicare	$689.71

Know your out-of-pocket cost for care.

All Charges