Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

2.7MM TI VA-LOCKING PLATE SMALL

Facility

$1,638.00

Service Code	HCPCS C1713
Hospital Charge Code	8748481
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 SMALL

Facility

$1,638.00

Service Code	HCPCS C1713
Hospital Charge Code	8748481
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

2.7MM TI VA LOCKING SCREW 32MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748723
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 TI VA LOCKING SCREW 32MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748723
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 TI VA LOCKING SCREW 36MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748725
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 TI VA LOCKING SCREW 36MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748725
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 TI VA LOCKING SCREW 44MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748727
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 TI VA LOCKING SCREW 44MM

Facility

$211.00

Service Code	HCPCS C1713
Hospital Charge Code	8748727
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 X 12MM LOCKING SCREW

Facility

$333.00

Service Code	HCPCS C1713
Hospital Charge Code	8834633
Hospital Revenue Code	278
Min. Negotiated Rate	$149.85
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Aetna of IA Medicare	$189.81
Rate for Payer: Amerigroup Medicaid	$192.07
Rate for Payer: Amerigroup Medicare	$151.35
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$149.85
Rate for Payer: Iowa Total Care Managed Medicaid	$190.21
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Medical Associates Managed Medicare	$149.85
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: Molina Healthcare Managed Medicaid	$193.01
Rate for Payer: Partners Health Alliance Commercial	$172.33
Rate for Payer: United Healthcare Commercial	$299.70
Rate for Payer: United Healthcare Managed Medicare	$196.47

2.7MM X 12MM LOCKING SCREW

Facility

$333.00

Service Code	HCPCS C1713
Hospital Charge Code	8834633
Hospital Revenue Code	278
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: United Healthcare Commercial	$299.70

2.7MM X 20MM NON LOCKING SCREW

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8834631
Hospital Revenue Code	278
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.47
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

2.7MM X 20MM NON LOCKING SCREW

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8834631
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

2.7MM X 24MM NON LOCKING SCREW

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8956478
Hospital Revenue Code	278
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: United Healthcare Commercial	$194.40

2.7MM X 24MM NON LOCKING SCREW

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8956478
Hospital Revenue Code	278
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Aetna of IA Medicare	$123.12
Rate for Payer: Amerigroup Medicaid	$124.59
Rate for Payer: Amerigroup Medicare	$98.17
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$97.20
Rate for Payer: Iowa Total Care Managed Medicaid	$123.38
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Medical Associates Managed Medicare	$97.20
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: Molina Healthcare Managed Medicaid	$125.19
Rate for Payer: Partners Health Alliance Commercial	$111.78
Rate for Payer: United Healthcare Commercial	$194.40
Rate for Payer: United Healthcare Managed Medicare	$127.44

2.7MM X 26MM NON LOCKING SCREW

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8956480
Hospital Revenue Code	278
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Aetna of IA Medicare	$123.12
Rate for Payer: Amerigroup Medicaid	$124.59
Rate for Payer: Amerigroup Medicare	$98.17
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$97.20
Rate for Payer: Iowa Total Care Managed Medicaid	$123.38
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Medical Associates Managed Medicare	$97.20
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: Molina Healthcare Managed Medicaid	$125.19
Rate for Payer: Partners Health Alliance Commercial	$111.78
Rate for Payer: United Healthcare Commercial	$194.40
Rate for Payer: United Healthcare Managed Medicare	$127.44

2.7MM X 26MM NON LOCKING SCREW

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8956480
Hospital Revenue Code	278
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: United Healthcare Commercial	$194.40

2.7MM X 28MM NON LOCKING SCREW

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8956482
Hospital Revenue Code	278
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: United Healthcare Commercial	$194.40

2.7MM X 28MM NON LOCKING SCREW

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8956482
Hospital Revenue Code	278
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Aetna of IA Medicare	$123.12
Rate for Payer: Amerigroup Medicaid	$124.59
Rate for Payer: Amerigroup Medicare	$98.17
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$97.20
Rate for Payer: Iowa Total Care Managed Medicaid	$123.38
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Medical Associates Managed Medicare	$97.20
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: Molina Healthcare Managed Medicaid	$125.19
Rate for Payer: Partners Health Alliance Commercial	$111.78
Rate for Payer: United Healthcare Commercial	$194.40
Rate for Payer: United Healthcare Managed Medicare	$127.44

28035 Release tarsal tunnel- tibial nerve

Professional

Both

$1,771.00

Service Code	CPT 28035
Hospital Charge Code	8799133
Hospital Revenue Code	975
Min. Negotiated Rate	$806.38
Max. Negotiated Rate	$1,328.25
Rate for Payer: Cash Price	$1,416.80
Rate for Payer: Cash Price	$1,416.80
Rate for Payer: Medical Associates Commercial	$1,328.25
Rate for Payer: Midlands Choice Commercial	$1,239.70
Rate for Payer: Partners Health Alliance Commercial	$1,328.25
Rate for Payer: United Healthcare Commercial	$806.38

28080 Excision interdigital morton neuroma single each

Professional

Both

$1,772.00

Service Code	CPT 28080
Hospital Charge Code	8799134
Hospital Revenue Code	975
Min. Negotiated Rate	$807.46
Max. Negotiated Rate	$1,329.00
Rate for Payer: Cash Price	$1,417.60
Rate for Payer: Cash Price	$1,417.60
Rate for Payer: Medical Associates Commercial	$1,329.00
Rate for Payer: Midlands Choice Commercial	$1,240.40
Rate for Payer: Partners Health Alliance Commercial	$1,329.00
Rate for Payer: United Healthcare Commercial	$807.46

28090 Excision ganglion cyst- foot

Professional

Both

$1,585.00

Service Code	CPT 28090
Hospital Charge Code	8799135
Hospital Revenue Code	975
Min. Negotiated Rate	$717.31
Max. Negotiated Rate	$1,188.75
Rate for Payer: Cash Price	$1,268.00
Rate for Payer: Cash Price	$1,268.00
Rate for Payer: Medical Associates Commercial	$1,188.75
Rate for Payer: Midlands Choice Commercial	$1,109.50
Rate for Payer: Partners Health Alliance Commercial	$1,188.75
Rate for Payer: United Healthcare Commercial	$717.31

28108 Excision/curettage of bone cyst/B9 tumor phalanges of foot

Professional

Both

$1,486.00

Service Code	CPT 28108
Hospital Charge Code	8799136
Hospital Revenue Code	975
Min. Negotiated Rate	$674.98
Max. Negotiated Rate	$1,114.50
Rate for Payer: Cash Price	$1,188.80
Rate for Payer: Cash Price	$1,188.80
Rate for Payer: Medical Associates Commercial	$1,114.50
Rate for Payer: Midlands Choice Commercial	$1,040.20
Rate for Payer: Partners Health Alliance Commercial	$1,114.50
Rate for Payer: United Healthcare Commercial	$674.98

28112 Ostectomy complete other metatarsal head (2nd 3rd or 4th)

Professional

Both

$1,646.00

Service Code	CPT 28112
Hospital Charge Code	8799137
Hospital Revenue Code	975
Min. Negotiated Rate	$747.54
Max. Negotiated Rate	$1,234.50
Rate for Payer: Cash Price	$1,316.80
Rate for Payer: Cash Price	$1,316.80
Rate for Payer: Medical Associates Commercial	$1,234.50
Rate for Payer: Midlands Choice Commercial	$1,152.20
Rate for Payer: Partners Health Alliance Commercial	$1,234.50
Rate for Payer: United Healthcare Commercial	$747.54

28122 Partial excision; tarsal/metatarsal bone

Professional

Both

$2,003.00

Service Code	CPT 28122
Hospital Charge Code	8799138
Hospital Revenue Code	975
Min. Negotiated Rate	$916.03
Max. Negotiated Rate	$1,502.25
Rate for Payer: Cash Price	$1,602.40
Rate for Payer: Cash Price	$1,602.40
Rate for Payer: Medical Associates Commercial	$1,502.25
Rate for Payer: Midlands Choice Commercial	$1,402.10
Rate for Payer: Partners Health Alliance Commercial	$1,502.25
Rate for Payer: United Healthcare Commercial	$916.03

28234 Tenotomy open extensor foot or toe each tendon

Professional

Both

$1,378.00

Service Code	CPT 28234
Hospital Charge Code	8799139
Hospital Revenue Code	975
Min. Negotiated Rate	$627.78
Max. Negotiated Rate	$1,033.50
Rate for Payer: Cash Price	$1,102.40
Rate for Payer: Cash Price	$1,102.40
Rate for Payer: Medical Associates Commercial	$1,033.50
Rate for Payer: Midlands Choice Commercial	$964.60
Rate for Payer: Partners Health Alliance Commercial	$1,033.50
Rate for Payer: United Healthcare Commercial	$627.78

Know your out-of-pocket cost for care.

All Charges