Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

2.4MM X 16MM CANNULATED SCREW

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8470644
Hospital Revenue Code	278
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: United Healthcare Commercial	$283.50

2.4mmx24mm CANNULATED SCREW

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8465010
Hospital Revenue Code	278
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: United Healthcare Commercial	$283.50

2.4mmx24mm CANNULATED SCREW

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8465010
Hospital Revenue Code	278
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Aetna of IA Medicare	$179.55
Rate for Payer: Amerigroup Medicaid	$181.69
Rate for Payer: Amerigroup Medicare	$143.17
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$141.75
Rate for Payer: Iowa Total Care Managed Medicaid	$179.93
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Medical Associates Managed Medicare	$141.75
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: Molina Healthcare Managed Medicaid	$182.57
Rate for Payer: Partners Health Alliance Commercial	$163.01
Rate for Payer: United Healthcare Commercial	$283.50
Rate for Payer: United Healthcare Managed Medicare	$185.85

2.4MMX30MM CANNULATED SCREW

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8465012
Hospital Revenue Code	278
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: United Healthcare Commercial	$283.50

2.4MMX30MM CANNULATED SCREW

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8465012
Hospital Revenue Code	278
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Aetna of IA Medicare	$179.55
Rate for Payer: Amerigroup Medicaid	$181.69
Rate for Payer: Amerigroup Medicare	$143.17
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$141.75
Rate for Payer: Iowa Total Care Managed Medicaid	$179.93
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Medical Associates Managed Medicare	$141.75
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: Molina Healthcare Managed Medicaid	$182.57
Rate for Payer: Partners Health Alliance Commercial	$163.01
Rate for Payer: United Healthcare Commercial	$283.50
Rate for Payer: United Healthcare Managed Medicare	$185.85

2.4MMX32MM LDA SCREW

Facility

$486.00

Service Code	HCPCS C1713
Hospital Charge Code	8465014
Hospital Revenue Code	278
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of IA Commercial	$437.40
Rate for Payer: Aetna of IA Medical Rental Products	$437.40
Rate for Payer: Aetna of IA Medicare	$277.02
Rate for Payer: Amerigroup Medicaid	$280.32
Rate for Payer: Amerigroup Medicare	$220.89
Rate for Payer: Cash Price	$388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$364.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$218.70
Rate for Payer: Iowa Total Care Managed Medicaid	$277.60
Rate for Payer: Medical Associates Commercial	$364.50
Rate for Payer: Medical Associates Managed Medicare	$218.70
Rate for Payer: Midlands Choice Commercial	$340.20
Rate for Payer: Molina Healthcare Managed Medicaid	$281.69
Rate for Payer: Partners Health Alliance Commercial	$251.50
Rate for Payer: United Healthcare Commercial	$437.40
Rate for Payer: United Healthcare Managed Medicare	$286.74

2.4MMX32MM LDA SCREW

Facility

$486.00

Service Code	HCPCS C1713
Hospital Charge Code	8465014
Hospital Revenue Code	278
Min. Negotiated Rate	$340.20
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of IA Commercial	$437.40
Rate for Payer: Aetna of IA Medical Rental Products	$437.40
Rate for Payer: Cash Price	$388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$364.50
Rate for Payer: Medical Associates Commercial	$364.50
Rate for Payer: Midlands Choice Commercial	$340.20
Rate for Payer: United Healthcare Commercial	$437.40

2.4MM X 34MM TIGER CANN LDA SCREW

Facility

$387.00

Service Code	HCPCS C1713
Hospital Charge Code	8994548
Hospital Revenue Code	278
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$348.30
Rate for Payer: Aetna of IA Commercial	$348.30
Rate for Payer: Aetna of IA Medical Rental Products	$348.30
Rate for Payer: Cash Price	$309.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$290.25
Rate for Payer: Medical Associates Commercial	$290.25
Rate for Payer: Midlands Choice Commercial	$270.90
Rate for Payer: United Healthcare Commercial	$348.30

2.4MM X 34MM TIGER CANN LDA SCREW

Facility

$387.00

Service Code	HCPCS C1713
Hospital Charge Code	8994548
Hospital Revenue Code	278
Min. Negotiated Rate	$174.15
Max. Negotiated Rate	$348.30
Rate for Payer: Aetna of IA Commercial	$348.30
Rate for Payer: Aetna of IA Medical Rental Products	$348.30
Rate for Payer: Aetna of IA Medicare	$220.59
Rate for Payer: Amerigroup Medicaid	$223.22
Rate for Payer: Amerigroup Medicare	$175.89
Rate for Payer: Cash Price	$309.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$290.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$174.15
Rate for Payer: Iowa Total Care Managed Medicaid	$221.05
Rate for Payer: Medical Associates Commercial	$290.25
Rate for Payer: Medical Associates Managed Medicare	$174.15
Rate for Payer: Midlands Choice Commercial	$270.90
Rate for Payer: Molina Healthcare Managed Medicaid	$224.31
Rate for Payer: Partners Health Alliance Commercial	$200.27
Rate for Payer: United Healthcare Commercial	$348.30
Rate for Payer: United Healthcare Managed Medicare	$228.33

2.4MM X 42MM TIGER CANN LDA SCREW

Facility

$387.00

Service Code	HCPCS C1713
Hospital Charge Code	8994550
Hospital Revenue Code	278
Min. Negotiated Rate	$174.15
Max. Negotiated Rate	$348.30
Rate for Payer: Aetna of IA Commercial	$348.30
Rate for Payer: Aetna of IA Medical Rental Products	$348.30
Rate for Payer: Aetna of IA Medicare	$220.59
Rate for Payer: Amerigroup Medicaid	$223.22
Rate for Payer: Amerigroup Medicare	$175.89
Rate for Payer: Cash Price	$309.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$290.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$174.15
Rate for Payer: Iowa Total Care Managed Medicaid	$221.05
Rate for Payer: Medical Associates Commercial	$290.25
Rate for Payer: Medical Associates Managed Medicare	$174.15
Rate for Payer: Midlands Choice Commercial	$270.90
Rate for Payer: Molina Healthcare Managed Medicaid	$224.31
Rate for Payer: Partners Health Alliance Commercial	$200.27
Rate for Payer: United Healthcare Commercial	$348.30
Rate for Payer: United Healthcare Managed Medicare	$228.33

2.4MM X 42MM TIGER CANN LDA SCREW

Facility

$387.00

Service Code	HCPCS C1713
Hospital Charge Code	8994550
Hospital Revenue Code	278
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$348.30
Rate for Payer: Aetna of IA Commercial	$348.30
Rate for Payer: Aetna of IA Medical Rental Products	$348.30
Rate for Payer: Cash Price	$309.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$290.25
Rate for Payer: Medical Associates Commercial	$290.25
Rate for Payer: Midlands Choice Commercial	$270.90
Rate for Payer: United Healthcare Commercial	$348.30

2.4MMX46MM TIGER CANNULATED SCREW

Facility

$486.00

Service Code	HCPCS C1713
Hospital Charge Code	8463482
Hospital Revenue Code	278
Min. Negotiated Rate	$340.20
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of IA Commercial	$437.40
Rate for Payer: Aetna of IA Medical Rental Products	$437.40
Rate for Payer: Cash Price	$388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$364.50
Rate for Payer: Medical Associates Commercial	$364.50
Rate for Payer: Midlands Choice Commercial	$340.20
Rate for Payer: United Healthcare Commercial	$437.40

2.4MMX46MM TIGER CANNULATED SCREW

Facility

$486.00

Service Code	HCPCS C1713
Hospital Charge Code	8463482
Hospital Revenue Code	278
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of IA Commercial	$437.40
Rate for Payer: Aetna of IA Medical Rental Products	$437.40
Rate for Payer: Aetna of IA Medicare	$277.02
Rate for Payer: Amerigroup Medicaid	$280.32
Rate for Payer: Amerigroup Medicare	$220.89
Rate for Payer: Cash Price	$388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$364.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$218.70
Rate for Payer: Iowa Total Care Managed Medicaid	$277.60
Rate for Payer: Medical Associates Commercial	$364.50
Rate for Payer: Medical Associates Managed Medicare	$218.70
Rate for Payer: Midlands Choice Commercial	$340.20
Rate for Payer: Molina Healthcare Managed Medicaid	$281.69
Rate for Payer: Partners Health Alliance Commercial	$251.50
Rate for Payer: United Healthcare Commercial	$437.40
Rate for Payer: United Healthcare Managed Medicare	$286.74

2.4MMX48MM TIGER CANNULATED SCREW

Facility

$486.00

Service Code	HCPCS C1713
Hospital Charge Code	8463484
Hospital Revenue Code	278
Min. Negotiated Rate	$340.20
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of IA Commercial	$437.40
Rate for Payer: Aetna of IA Medical Rental Products	$437.40
Rate for Payer: Cash Price	$388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$364.50
Rate for Payer: Medical Associates Commercial	$364.50
Rate for Payer: Midlands Choice Commercial	$340.20
Rate for Payer: United Healthcare Commercial	$437.40

2.4MMX48MM TIGER CANNULATED SCREW

Facility

$486.00

Service Code	HCPCS C1713
Hospital Charge Code	8463484
Hospital Revenue Code	278
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of IA Commercial	$437.40
Rate for Payer: Aetna of IA Medical Rental Products	$437.40
Rate for Payer: Aetna of IA Medicare	$277.02
Rate for Payer: Amerigroup Medicaid	$280.32
Rate for Payer: Amerigroup Medicare	$220.89
Rate for Payer: Cash Price	$388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$364.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$218.70
Rate for Payer: Iowa Total Care Managed Medicaid	$277.60
Rate for Payer: Medical Associates Commercial	$364.50
Rate for Payer: Medical Associates Managed Medicare	$218.70
Rate for Payer: Midlands Choice Commercial	$340.20
Rate for Payer: Molina Healthcare Managed Medicaid	$281.69
Rate for Payer: Partners Health Alliance Commercial	$251.50
Rate for Payer: United Healthcare Commercial	$437.40
Rate for Payer: United Healthcare Managed Medicare	$286.74

2.4 THREAD PILOT DRILL,TWO-STEP HAMMER TOE INST (DISP)

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8749765
Hospital Revenue Code	278
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Aetna of IA Medicare	$179.55
Rate for Payer: Amerigroup Medicaid	$181.69
Rate for Payer: Amerigroup Medicare	$143.17
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$141.75
Rate for Payer: Iowa Total Care Managed Medicaid	$179.93
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Medical Associates Managed Medicare	$141.75
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: Molina Healthcare Managed Medicaid	$182.57
Rate for Payer: Partners Health Alliance Commercial	$163.01
Rate for Payer: United Healthcare Commercial	$283.50
Rate for Payer: United Healthcare Managed Medicare	$185.85

2.4 THREAD PILOT DRILL,TWO-STEP HAMMER TOE INST (DISP)

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8749765
Hospital Revenue Code	278
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: United Healthcare Commercial	$283.50

25000 Dequervains release

Professional

Both

$1,246.00

Service Code	CPT 25000
Hospital Charge Code	8981178
Hospital Revenue Code	975
Min. Negotiated Rate	$511.62
Max. Negotiated Rate	$934.50
Rate for Payer: Cash Price	$996.80
Rate for Payer: Cash Price	$996.80
Rate for Payer: Medical Associates Commercial	$934.50
Rate for Payer: Midlands Choice Commercial	$872.20
Rate for Payer: Partners Health Alliance Commercial	$934.50
Rate for Payer: United Healthcare Commercial	$511.62

25111 Ganglion Cyst removal of Wrist

Professional

Both

$1,171.00

Service Code	CPT 25111
Hospital Charge Code	8981172
Hospital Revenue Code	975
Min. Negotiated Rate	$485.04
Max. Negotiated Rate	$878.25
Rate for Payer: Cash Price	$936.80
Rate for Payer: Cash Price	$936.80
Rate for Payer: Medical Associates Commercial	$878.25
Rate for Payer: Midlands Choice Commercial	$819.70
Rate for Payer: Partners Health Alliance Commercial	$878.25
Rate for Payer: United Healthcare Commercial	$485.04

25112 Excision tumor soft tissue of neck/ant thorax sub q 3 cm +

Professional

Both

$1,500.00

Service Code	CPT 25112
Hospital Charge Code	8799118
Hospital Revenue Code	983
Min. Negotiated Rate	$584.77
Max. Negotiated Rate	$1,125.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Medical Associates Commercial	$1,125.00
Rate for Payer: Midlands Choice Commercial	$1,050.00
Rate for Payer: Partners Health Alliance Commercial	$1,125.00
Rate for Payer: United Healthcare Commercial	$584.77

25447 CMC arthroplasty

Professional

Both

$2,953.00

Service Code	CPT 25447
Hospital Charge Code	8981179
Hospital Revenue Code	975
Min. Negotiated Rate	$1,255.28
Max. Negotiated Rate	$2,214.75
Rate for Payer: Cash Price	$2,362.40
Rate for Payer: Cash Price	$2,362.40
Rate for Payer: Medical Associates Commercial	$2,214.75
Rate for Payer: Midlands Choice Commercial	$2,067.10
Rate for Payer: Partners Health Alliance Commercial	$2,214.75
Rate for Payer: United Healthcare Commercial	$1,255.28

25607 ORIF distal radius- extra articular

Professional

Both

$2,636.00

Service Code	CPT 25607
Hospital Charge Code	8981175
Hospital Revenue Code	975
Min. Negotiated Rate	$1,111.46
Max. Negotiated Rate	$1,977.00
Rate for Payer: Cash Price	$2,108.80
Rate for Payer: Cash Price	$2,108.80
Rate for Payer: Medical Associates Commercial	$1,977.00
Rate for Payer: Midlands Choice Commercial	$1,845.20
Rate for Payer: Partners Health Alliance Commercial	$1,977.00
Rate for Payer: United Healthcare Commercial	$1,111.46

25608 ORIF distal radius Intra articular 2 fragments

Professional

Both

$2,943.00

Service Code	CPT 25608
Hospital Charge Code	8981176
Hospital Revenue Code	975
Min. Negotiated Rate	$1,246.86
Max. Negotiated Rate	$2,207.25
Rate for Payer: Cash Price	$2,354.40
Rate for Payer: Cash Price	$2,354.40
Rate for Payer: Medical Associates Commercial	$2,207.25
Rate for Payer: Midlands Choice Commercial	$2,060.10
Rate for Payer: Partners Health Alliance Commercial	$2,207.25
Rate for Payer: United Healthcare Commercial	$1,246.86

25609 ORIF distal radius 3 fragments

Professional

Both

$3,725.00

Service Code	CPT 25609
Hospital Charge Code	8981177
Hospital Revenue Code	975
Min. Negotiated Rate	$1,587.01
Max. Negotiated Rate	$2,793.75
Rate for Payer: Cash Price	$2,980.00
Rate for Payer: Cash Price	$2,980.00
Rate for Payer: Medical Associates Commercial	$2,793.75
Rate for Payer: Midlands Choice Commercial	$2,607.50
Rate for Payer: Partners Health Alliance Commercial	$2,793.75
Rate for Payer: United Healthcare Commercial	$1,587.01

26055 Trigger finger release

Professional

Both

$2,077.00

Service Code	CPT 26055
Hospital Charge Code	8981190
Hospital Revenue Code	975
Min. Negotiated Rate	$819.15
Max. Negotiated Rate	$1,557.75
Rate for Payer: Cash Price	$1,661.60
Rate for Payer: Cash Price	$1,661.60
Rate for Payer: Medical Associates Commercial	$1,557.75
Rate for Payer: Midlands Choice Commercial	$1,453.90
Rate for Payer: Partners Health Alliance Commercial	$1,557.75
Rate for Payer: United Healthcare Commercial	$819.15

Know your out-of-pocket cost for care.

All Charges