Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

27652 Repair primary ruptured Achilles tendon; with graft

Professional

Both

$2,235.00

Service Code	CPT 27652
Hospital Charge Code	8799124
Hospital Revenue Code	975
Min. Negotiated Rate	$1,025.38
Max. Negotiated Rate	$1,676.25
Rate for Payer: Cash Price	$1,788.00
Rate for Payer: Cash Price	$1,788.00
Rate for Payer: Medical Associates Commercial	$1,676.25
Rate for Payer: Midlands Choice Commercial	$1,564.50
Rate for Payer: Partners Health Alliance Commercial	$1,676.25
Rate for Payer: United Healthcare Commercial	$1,025.38

27654 Repair secondary achilles tendon with/without graft

Professional

Both

$2,396.00

Service Code	CPT 27654
Hospital Charge Code	8799125
Hospital Revenue Code	975
Min. Negotiated Rate	$1,090.46
Max. Negotiated Rate	$1,797.00
Rate for Payer: Cash Price	$1,916.80
Rate for Payer: Cash Price	$1,916.80
Rate for Payer: Medical Associates Commercial	$1,797.00
Rate for Payer: Midlands Choice Commercial	$1,677.20
Rate for Payer: Partners Health Alliance Commercial	$1,797.00
Rate for Payer: United Healthcare Commercial	$1,090.46

27687 Gastrocnemius recession

Professional

Both

$1,524.00

Service Code	CPT 27687
Hospital Charge Code	8799126
Hospital Revenue Code	975
Min. Negotiated Rate	$694.34
Max. Negotiated Rate	$1,143.00
Rate for Payer: Cash Price	$1,219.20
Rate for Payer: Cash Price	$1,219.20
Rate for Payer: Medical Associates Commercial	$1,143.00
Rate for Payer: Midlands Choice Commercial	$1,066.80
Rate for Payer: Partners Health Alliance Commercial	$1,143.00
Rate for Payer: United Healthcare Commercial	$694.34

27691 Transfer single tendon; deep foot

Professional

Both

$2,503.00

Service Code	CPT 27691
Hospital Charge Code	8799127
Hospital Revenue Code	975
Min. Negotiated Rate	$1,132.85
Max. Negotiated Rate	$1,877.25
Rate for Payer: Cash Price	$2,002.40
Rate for Payer: Cash Price	$2,002.40
Rate for Payer: Medical Associates Commercial	$1,877.25
Rate for Payer: Midlands Choice Commercial	$1,752.10
Rate for Payer: Partners Health Alliance Commercial	$1,877.25
Rate for Payer: United Healthcare Commercial	$1,132.85

27698 Repair secondary disrupted ligament ankle collateral

Professional

Both

$2,145.00

Service Code	CPT 27698
Hospital Charge Code	8799128
Hospital Revenue Code	975
Min. Negotiated Rate	$975.15
Max. Negotiated Rate	$1,608.75
Rate for Payer: Cash Price	$1,716.00
Rate for Payer: Cash Price	$1,716.00
Rate for Payer: Medical Associates Commercial	$1,608.75
Rate for Payer: Midlands Choice Commercial	$1,501.50
Rate for Payer: Partners Health Alliance Commercial	$1,608.75
Rate for Payer: United Healthcare Commercial	$975.15

27769 Open treatment posterior malleolus fracture

Professional

Both

$2,452.00

Service Code	CPT 27769
Hospital Charge Code	8799129
Hospital Revenue Code	975
Min. Negotiated Rate	$1,102.80
Max. Negotiated Rate	$1,839.00
Rate for Payer: Cash Price	$1,961.60
Rate for Payer: Cash Price	$1,961.60
Rate for Payer: Medical Associates Commercial	$1,839.00
Rate for Payer: Midlands Choice Commercial	$1,716.40
Rate for Payer: Partners Health Alliance Commercial	$1,839.00
Rate for Payer: United Healthcare Commercial	$1,102.80

27792 Open treatment distal fibula fx including internal fixation

Professional

Both

$2,177.00

Service Code	CPT 27792
Hospital Charge Code	8799130
Hospital Revenue Code	975
Min. Negotiated Rate	$979.92
Max. Negotiated Rate	$1,632.75
Rate for Payer: Cash Price	$1,741.60
Rate for Payer: Cash Price	$1,741.60
Rate for Payer: Medical Associates Commercial	$1,632.75
Rate for Payer: Midlands Choice Commercial	$1,523.90
Rate for Payer: Partners Health Alliance Commercial	$1,632.75
Rate for Payer: United Healthcare Commercial	$979.92

2.77MM LOCKING SCREW 40MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8749293
Hospital Revenue Code	278
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$189.90
Rate for Payer: Aetna of IA Commercial	$189.90
Rate for Payer: Aetna of IA Medical Rental Products	$189.90
Rate for Payer: Cash Price	$168.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$158.25
Rate for Payer: Medical Associates Commercial	$158.25
Rate for Payer: Midlands Choice Commercial	$147.70
Rate for Payer: United Healthcare Commercial	$189.90

2.77MM LOCKING SCREW 40MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8749293
Hospital Revenue Code	278
Min. Negotiated Rate	$94.95
Max. Negotiated Rate	$189.90
Rate for Payer: Aetna of IA Commercial	$189.90
Rate for Payer: Aetna of IA Medical Rental Products	$189.90
Rate for Payer: Aetna of IA Medicare	$120.27
Rate for Payer: Amerigroup Medicaid	$121.70
Rate for Payer: Amerigroup Medicare	$95.90
Rate for Payer: Cash Price	$168.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$158.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$94.95
Rate for Payer: Iowa Total Care Managed Medicaid	$120.52
Rate for Payer: Medical Associates Commercial	$158.25
Rate for Payer: Medical Associates Managed Medicare	$94.95
Rate for Payer: Midlands Choice Commercial	$147.70
Rate for Payer: Molina Healthcare Managed Medicaid	$122.30
Rate for Payer: Partners Health Alliance Commercial	$109.19
Rate for Payer: United Healthcare Commercial	$189.90
Rate for Payer: United Healthcare Managed Medicare	$124.49

27822 Open treatment trimalleolar ankle fracture medial and/or lateral malleolus

Professional

Both

$2,914.00

Service Code	CPT 27822
Hospital Charge Code	8799131
Hospital Revenue Code	975
Min. Negotiated Rate	$1,310.46
Max. Negotiated Rate	$2,185.50
Rate for Payer: Cash Price	$2,331.20
Rate for Payer: Cash Price	$2,331.20
Rate for Payer: Medical Associates Commercial	$2,185.50
Rate for Payer: Midlands Choice Commercial	$2,039.80
Rate for Payer: Partners Health Alliance Commercial	$2,185.50
Rate for Payer: United Healthcare Commercial	$1,310.46

27823 Open treatment trimalleolar ankle fracture medial and/or lateral malleolus

Professional

Both

$3,268.00

Service Code	CPT 27823
Hospital Charge Code	8799132
Hospital Revenue Code	975
Min. Negotiated Rate	$1,481.86
Max. Negotiated Rate	$2,451.00
Rate for Payer: Cash Price	$2,614.40
Rate for Payer: Cash Price	$2,614.40
Rate for Payer: Medical Associates Commercial	$2,451.00
Rate for Payer: Midlands Choice Commercial	$2,287.60
Rate for Payer: Partners Health Alliance Commercial	$2,451.00
Rate for Payer: United Healthcare Commercial	$1,481.86

2.7MM LOCKING SCREW 38MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748477
Hospital Revenue Code	278
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$189.90
Rate for Payer: Aetna of IA Commercial	$189.90
Rate for Payer: Aetna of IA Medical Rental Products	$189.90
Rate for Payer: Cash Price	$168.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$158.25
Rate for Payer: Medical Associates Commercial	$158.25
Rate for Payer: Midlands Choice Commercial	$147.70
Rate for Payer: United Healthcare Commercial	$189.90

2.7MM LOCKING SCREW 38MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748477
Hospital Revenue Code	278
Min. Negotiated Rate	$94.95
Max. Negotiated Rate	$189.90
Rate for Payer: Aetna of IA Commercial	$189.90
Rate for Payer: Aetna of IA Medical Rental Products	$189.90
Rate for Payer: Aetna of IA Medicare	$120.27
Rate for Payer: Amerigroup Medicaid	$121.70
Rate for Payer: Amerigroup Medicare	$95.90
Rate for Payer: Cash Price	$168.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$158.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$94.95
Rate for Payer: Iowa Total Care Managed Medicaid	$120.52
Rate for Payer: Medical Associates Commercial	$158.25
Rate for Payer: Medical Associates Managed Medicare	$94.95
Rate for Payer: Midlands Choice Commercial	$147.70
Rate for Payer: Molina Healthcare Managed Medicaid	$122.30
Rate for Payer: Partners Health Alliance Commercial	$109.19
Rate for Payer: United Healthcare Commercial	$189.90
Rate for Payer: United Healthcare Managed Medicare	$124.49

2.7MM LOCKING SCREW X42MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748479
Hospital Revenue Code	278
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$189.90
Rate for Payer: Aetna of IA Commercial	$189.90
Rate for Payer: Aetna of IA Medical Rental Products	$189.90
Rate for Payer: Cash Price	$168.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$158.25
Rate for Payer: Medical Associates Commercial	$158.25
Rate for Payer: Midlands Choice Commercial	$147.70
Rate for Payer: United Healthcare Commercial	$189.90

2.7MM LOCKING SCREW X42MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748479
Hospital Revenue Code	278
Min. Negotiated Rate	$94.95
Max. Negotiated Rate	$189.90
Rate for Payer: Aetna of IA Commercial	$189.90
Rate for Payer: Aetna of IA Medical Rental Products	$189.90
Rate for Payer: Aetna of IA Medicare	$120.27
Rate for Payer: Amerigroup Medicaid	$121.70
Rate for Payer: Amerigroup Medicare	$95.90
Rate for Payer: Cash Price	$168.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$158.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$94.95
Rate for Payer: Iowa Total Care Managed Medicaid	$120.52
Rate for Payer: Medical Associates Commercial	$158.25
Rate for Payer: Medical Associates Managed Medicare	$94.95
Rate for Payer: Midlands Choice Commercial	$147.70
Rate for Payer: Molina Healthcare Managed Medicaid	$122.30
Rate for Payer: Partners Health Alliance Commercial	$109.19
Rate for Payer: United Healthcare Commercial	$189.90
Rate for Payer: United Healthcare Managed Medicare	$124.49

2.7MM METAPHYSEAL SCREW X 30MM

Facility

$71.00

Service Code	HCPCS C1713
Hospital Charge Code	8748469
Hospital Revenue Code	278
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89

2.7MM METAPHYSEAL SCREW X 30MM

Facility

$71.00

Service Code	HCPCS C1713
Hospital Charge Code	8748469
Hospital Revenue Code	278
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

2.7MM METAPHYSEAL SCREW X 40MM

Facility

$71.00

Service Code	HCPCS C1713
Hospital Charge Code	8748471
Hospital Revenue Code	278
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89

2.7MM METAPHYSEAL SCREW X 40MM

Facility

$71.00

Service Code	HCPCS C1713
Hospital Charge Code	8748471
Hospital Revenue Code	278
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

2.7MM METAPHYSEAL SCREW X 42MM

Facility

$71.00

Service Code	HCPCS C1713
Hospital Charge Code	8748473
Hospital Revenue Code	278
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

2.7MM METAPHYSEAL SCREW X 42MM

Facility

$71.00

Service Code	HCPCS C1713
Hospital Charge Code	8748473
Hospital Revenue Code	278
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89

2.7MM METAPHYSEAL SCREW X 44MM

Facility

$71.00

Service Code	HCPCS C1713
Hospital Charge Code	8748475
Hospital Revenue Code	278
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

2.7MM METAPHYSEAL SCREW X 44MM

Facility

$71.00

Service Code	HCPCS C1713
Hospital Charge Code	8748475
Hospital Revenue Code	278
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89

2.7MM TI VA LOCKING PLATE SM 58MM RIGHT

Facility

$1,638.00

Service Code	HCPCS C1713
Hospital Charge Code	8748729
Hospital Revenue Code	278
Min. Negotiated Rate	$737.10
Max. Negotiated Rate	$1,474.20
Rate for Payer: Aetna of IA Commercial	$1,474.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,474.20
Rate for Payer: Aetna of IA Medicare	$933.66
Rate for Payer: Amerigroup Medicaid	$944.80
Rate for Payer: Amerigroup Medicare	$744.47
Rate for Payer: Cash Price	$1,310.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,228.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$737.10
Rate for Payer: Iowa Total Care Managed Medicaid	$935.63
Rate for Payer: Medical Associates Commercial	$1,228.50
Rate for Payer: Medical Associates Managed Medicare	$737.10
Rate for Payer: Midlands Choice Commercial	$1,146.60
Rate for Payer: Molina Healthcare Managed Medicaid	$949.38
Rate for Payer: Partners Health Alliance Commercial	$847.66
Rate for Payer: United Healthcare Commercial	$1,474.20
Rate for Payer: United Healthcare Managed Medicare	$966.42

2.7MM TI VA LOCKING PLATE SM 58MM RIGHT

Facility

$1,638.00

Service Code	HCPCS C1713
Hospital Charge Code	8748729
Hospital Revenue Code	278
Min. Negotiated Rate	$1,146.60
Max. Negotiated Rate	$1,474.20
Rate for Payer: Aetna of IA Commercial	$1,474.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,474.20
Rate for Payer: Cash Price	$1,310.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,228.50
Rate for Payer: Medical Associates Commercial	$1,228.50
Rate for Payer: Midlands Choice Commercial	$1,146.60
Rate for Payer: United Healthcare Commercial	$1,474.20

Know your out-of-pocket cost for care.

All Charges