Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

28285 Correction hammertoe

Professional

Both

$1,808.00

Service Code	CPT 28285
Hospital Charge Code	8799140
Hospital Revenue Code	975
Min. Negotiated Rate	$825.30
Max. Negotiated Rate	$1,356.00
Rate for Payer: Cash Price	$1,446.40
Rate for Payer: Cash Price	$1,446.40
Rate for Payer: Medical Associates Commercial	$1,356.00
Rate for Payer: Midlands Choice Commercial	$1,265.60
Rate for Payer: Partners Health Alliance Commercial	$1,356.00
Rate for Payer: United Healthcare Commercial	$825.30

28288 Ostectomy partial metatarsal head

Professional

Both

$2,053.00

Service Code	CPT 28288
Hospital Charge Code	8799141
Hospital Revenue Code	975
Min. Negotiated Rate	$934.67
Max. Negotiated Rate	$1,539.75
Rate for Payer: Cash Price	$1,642.40
Rate for Payer: Cash Price	$1,642.40
Rate for Payer: Medical Associates Commercial	$1,539.75
Rate for Payer: Midlands Choice Commercial	$1,437.10
Rate for Payer: Partners Health Alliance Commercial	$1,539.75
Rate for Payer: United Healthcare Commercial	$934.67

28291 Hallux rigidus correction w/cheilectomy of 1st MTP w/ implant

Professional

Both

$2,451.00

Service Code	CPT 28291
Hospital Charge Code	8799142
Hospital Revenue Code	975
Min. Negotiated Rate	$1,124.80
Max. Negotiated Rate	$1,838.25
Rate for Payer: Cash Price	$1,960.80
Rate for Payer: Cash Price	$1,960.80
Rate for Payer: Medical Associates Commercial	$1,838.25
Rate for Payer: Midlands Choice Commercial	$1,715.70
Rate for Payer: Partners Health Alliance Commercial	$1,838.25
Rate for Payer: United Healthcare Commercial	$1,124.80

28295 Correction hallux valgus/w sesmoidectomy w/ proximal metarsal osteotomy

Professional

Both

$3,328.00

Service Code	CPT 28295
Hospital Charge Code	8799143
Hospital Revenue Code	975
Min. Negotiated Rate	$1,513.46
Max. Negotiated Rate	$2,496.00
Rate for Payer: Cash Price	$2,662.40
Rate for Payer: Cash Price	$2,662.40
Rate for Payer: Medical Associates Commercial	$2,496.00
Rate for Payer: Midlands Choice Commercial	$2,329.60
Rate for Payer: Partners Health Alliance Commercial	$2,496.00
Rate for Payer: United Healthcare Commercial	$1,513.46

28296 Correction hallux valgus (bunionectomy) w/sesamoidectomy

Professional

Both

$3,070.00

Service Code	CPT 28296
Hospital Charge Code	8799144
Hospital Revenue Code	975
Min. Negotiated Rate	$1,394.24
Max. Negotiated Rate	$2,302.50
Rate for Payer: Cash Price	$2,456.00
Rate for Payer: Cash Price	$2,456.00
Rate for Payer: Medical Associates Commercial	$2,302.50
Rate for Payer: Midlands Choice Commercial	$2,149.00
Rate for Payer: Partners Health Alliance Commercial	$2,302.50
Rate for Payer: United Healthcare Commercial	$1,394.24

28308 Osteotomy w/or w/o lengthening shortening; metatarsal

Professional

Both

$1,916.00

Service Code	CPT 28308
Hospital Charge Code	8799145
Hospital Revenue Code	975
Min. Negotiated Rate	$872.62
Max. Negotiated Rate	$1,437.00
Rate for Payer: Cash Price	$1,532.80
Rate for Payer: Cash Price	$1,532.80
Rate for Payer: Medical Associates Commercial	$1,437.00
Rate for Payer: Midlands Choice Commercial	$1,341.20
Rate for Payer: Partners Health Alliance Commercial	$1,437.00
Rate for Payer: United Healthcare Commercial	$872.62

28313 Recontruction angular deformity to toe soft tissue procedures only

Professional

Both

$1,754.00

Service Code	CPT 28313
Hospital Charge Code	8799146
Hospital Revenue Code	975
Min. Negotiated Rate	$802.77
Max. Negotiated Rate	$1,315.50
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Medical Associates Commercial	$1,315.50
Rate for Payer: Midlands Choice Commercial	$1,227.80
Rate for Payer: Partners Health Alliance Commercial	$1,315.50
Rate for Payer: United Healthcare Commercial	$802.77

28415 Open treatment of calcaneal fracture

Professional

Both

$3,751.00

Service Code	CPT 28415
Hospital Charge Code	8799147
Hospital Revenue Code	975
Min. Negotiated Rate	$1,704.48
Max. Negotiated Rate	$2,813.25
Rate for Payer: Cash Price	$3,000.80
Rate for Payer: Cash Price	$3,000.80
Rate for Payer: Medical Associates Commercial	$2,813.25
Rate for Payer: Midlands Choice Commercial	$2,625.70
Rate for Payer: Partners Health Alliance Commercial	$2,813.25
Rate for Payer: United Healthcare Commercial	$1,704.48

28485 Open treatment of metatarsal fracture; includes internal fixation

Professional

Both

$1,827.00

Service Code	CPT 28485
Hospital Charge Code	8799148
Hospital Revenue Code	975
Min. Negotiated Rate	$846.51
Max. Negotiated Rate	$1,370.25
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Medical Associates Commercial	$1,370.25
Rate for Payer: Midlands Choice Commercial	$1,278.90
Rate for Payer: Partners Health Alliance Commercial	$1,370.25
Rate for Payer: United Healthcare Commercial	$846.51

28740 Arthrodesis midtarsal or tarsometatarsal single joint

Professional

Both

$2,823.00

Service Code	CPT 28740
Hospital Charge Code	8799149
Hospital Revenue Code	975
Min. Negotiated Rate	$1,282.46
Max. Negotiated Rate	$2,117.25
Rate for Payer: Cash Price	$2,258.40
Rate for Payer: Cash Price	$2,258.40
Rate for Payer: Medical Associates Commercial	$2,117.25
Rate for Payer: Midlands Choice Commercial	$1,976.10
Rate for Payer: Partners Health Alliance Commercial	$2,117.25
Rate for Payer: United Healthcare Commercial	$1,282.46

28820 Amputate toe metatarsophalangeal joint

Professional

Both

$1,887.00

Service Code	CPT 28820
Hospital Charge Code	8799150
Hospital Revenue Code	975
Min. Negotiated Rate	$854.35
Max. Negotiated Rate	$1,415.25
Rate for Payer: Cash Price	$1,509.60
Rate for Payer: Cash Price	$1,509.60
Rate for Payer: Medical Associates Commercial	$1,415.25
Rate for Payer: Midlands Choice Commercial	$1,320.90
Rate for Payer: Partners Health Alliance Commercial	$1,415.25
Rate for Payer: United Healthcare Commercial	$854.35

28825 Amputate toe interphalangeal joint

Professional

Both

$1,807.00

Service Code	CPT 28825
Hospital Charge Code	8799151
Hospital Revenue Code	975
Min. Negotiated Rate	$817.54
Max. Negotiated Rate	$1,355.25
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Medical Associates Commercial	$1,355.25
Rate for Payer: Midlands Choice Commercial	$1,264.90
Rate for Payer: Partners Health Alliance Commercial	$1,355.25
Rate for Payer: United Healthcare Commercial	$817.54

29580 APPLICATION OF PASTE BOOT (UNNA)

Professional

Both

$210.00

Service Code	CPT 29580
Hospital Charge Code	8799153
Hospital Revenue Code	975
Min. Negotiated Rate	$94.99
Max. Negotiated Rate	$157.50
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cash Price	$168.00
Rate for Payer: Medical Associates Commercial	$157.50
Rate for Payer: Midlands Choice Commercial	$147.00
Rate for Payer: Partners Health Alliance Commercial	$157.50
Rate for Payer: United Healthcare Commercial	$94.99

29581 COMPRESSION MULTILAYER BELOW KNEE

Professional

Both

$296.00

Service Code	CPT 29581
Hospital Charge Code	8799154
Hospital Revenue Code	975
Min. Negotiated Rate	$135.70
Max. Negotiated Rate	$222.00
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cash Price	$236.80
Rate for Payer: Medical Associates Commercial	$222.00
Rate for Payer: Midlands Choice Commercial	$207.20
Rate for Payer: Partners Health Alliance Commercial	$222.00
Rate for Payer: United Healthcare Commercial	$135.70

29807 Arthroscopy shoulder surgical repair of SLAP lesion

Professional

Both

$3,485.00

Service Code	CPT 29807
Hospital Charge Code	8799155
Hospital Revenue Code	975
Min. Negotiated Rate	$1,563.97
Max. Negotiated Rate	$2,613.75
Rate for Payer: Cash Price	$2,788.00
Rate for Payer: Cash Price	$2,788.00
Rate for Payer: Medical Associates Commercial	$2,613.75
Rate for Payer: Midlands Choice Commercial	$2,439.50
Rate for Payer: Partners Health Alliance Commercial	$2,613.75
Rate for Payer: United Healthcare Commercial	$1,563.97

29826 Arthroscopy shoulder surgical; decompression of subacromial space

Professional

Both

$591.00

Service Code	CPT 29826
Hospital Charge Code	8799156
Hospital Revenue Code	975
Min. Negotiated Rate	$264.70
Max. Negotiated Rate	$443.25
Rate for Payer: Cash Price	$472.80
Rate for Payer: Cash Price	$472.80
Rate for Payer: Medical Associates Commercial	$443.25
Rate for Payer: Midlands Choice Commercial	$413.70
Rate for Payer: Partners Health Alliance Commercial	$443.25
Rate for Payer: United Healthcare Commercial	$264.70

29827 Arthroscopy shoulder surgical; with rotator cuff repair

Professional

Both

$3,542.00

Service Code	CPT 29827
Hospital Charge Code	8799157
Hospital Revenue Code	975
Min. Negotiated Rate	$1,619.47
Max. Negotiated Rate	$2,656.50
Rate for Payer: Cash Price	$2,833.60
Rate for Payer: Cash Price	$2,833.60
Rate for Payer: Medical Associates Commercial	$2,656.50
Rate for Payer: Midlands Choice Commercial	$2,479.40
Rate for Payer: Partners Health Alliance Commercial	$2,656.50
Rate for Payer: United Healthcare Commercial	$1,619.47

29867 Arthroscopy knee surgical; osteochondral allograft

Professional

Both

$4,311.00

Service Code	CPT 29867
Hospital Charge Code	8799158
Hospital Revenue Code	975
Min. Negotiated Rate	$1,930.86
Max. Negotiated Rate	$3,233.25
Rate for Payer: Cash Price	$3,448.80
Rate for Payer: Cash Price	$3,448.80
Rate for Payer: Medical Associates Commercial	$3,233.25
Rate for Payer: Midlands Choice Commercial	$3,017.70
Rate for Payer: Partners Health Alliance Commercial	$3,233.25
Rate for Payer: United Healthcare Commercial	$1,930.86

29874 Arthroscopy; knee with removal of loose/foreign body

Professional

Both

$1,801.00

Service Code	CPT 29874
Hospital Charge Code	8799159
Hospital Revenue Code	975
Min. Negotiated Rate	$812.16
Max. Negotiated Rate	$1,350.75
Rate for Payer: Cash Price	$1,440.80
Rate for Payer: Cash Price	$1,440.80
Rate for Payer: Medical Associates Commercial	$1,350.75
Rate for Payer: Midlands Choice Commercial	$1,260.70
Rate for Payer: Partners Health Alliance Commercial	$1,350.75
Rate for Payer: United Healthcare Commercial	$812.16

29877 Arthroscopy knee w/debridement/shaving of cartilage (chondroplasty)

Professional

Both

$2,087.00

Service Code	CPT 29877
Hospital Charge Code	8799160
Hospital Revenue Code	975
Min. Negotiated Rate	$937.68
Max. Negotiated Rate	$1,565.25
Rate for Payer: Cash Price	$1,669.60
Rate for Payer: Cash Price	$1,669.60
Rate for Payer: Medical Associates Commercial	$1,565.25
Rate for Payer: Midlands Choice Commercial	$1,460.90
Rate for Payer: Partners Health Alliance Commercial	$1,565.25
Rate for Payer: United Healthcare Commercial	$937.68

29879 Arthroscopy knee surgical; abrasion arthroplasty-drilling/microfracture

Professional

Both

$2,223.00

Service Code	CPT 29879
Hospital Charge Code	8799161
Hospital Revenue Code	975
Min. Negotiated Rate	$999.55
Max. Negotiated Rate	$1,667.25
Rate for Payer: Cash Price	$1,778.40
Rate for Payer: Cash Price	$1,778.40
Rate for Payer: Medical Associates Commercial	$1,667.25
Rate for Payer: Midlands Choice Commercial	$1,556.10
Rate for Payer: Partners Health Alliance Commercial	$1,667.25
Rate for Payer: United Healthcare Commercial	$999.55

29880 Arthroscopy; knee with meniscenctomy medial/lateral w/shaving

Professional

Both

$1,885.00

Service Code	CPT 29880
Hospital Charge Code	8799162
Hospital Revenue Code	975
Min. Negotiated Rate	$848.00
Max. Negotiated Rate	$1,413.75
Rate for Payer: Cash Price	$1,508.00
Rate for Payer: Cash Price	$1,508.00
Rate for Payer: Medical Associates Commercial	$1,413.75
Rate for Payer: Midlands Choice Commercial	$1,319.50
Rate for Payer: Partners Health Alliance Commercial	$1,413.75
Rate for Payer: United Healthcare Commercial	$848.00

29881 Arthroscopy knee surgical; with meniscectomy (medial OR lateral)

Professional

Both

$1,816.00

Service Code	CPT 29881
Hospital Charge Code	8799163
Hospital Revenue Code	975
Min. Negotiated Rate	$816.85
Max. Negotiated Rate	$1,362.00
Rate for Payer: Cash Price	$1,452.80
Rate for Payer: Cash Price	$1,452.80
Rate for Payer: Medical Associates Commercial	$1,362.00
Rate for Payer: Midlands Choice Commercial	$1,271.20
Rate for Payer: Partners Health Alliance Commercial	$1,362.00
Rate for Payer: United Healthcare Commercial	$816.85

29893 Endoscopic plantar fasciotomy

Professional

Both

$2,136.00

Service Code	CPT 29893
Hospital Charge Code	8799164
Hospital Revenue Code	975
Min. Negotiated Rate	$978.38
Max. Negotiated Rate	$1,602.00
Rate for Payer: Cash Price	$1,708.80
Rate for Payer: Cash Price	$1,708.80
Rate for Payer: Medical Associates Commercial	$1,602.00
Rate for Payer: Midlands Choice Commercial	$1,495.20
Rate for Payer: Partners Health Alliance Commercial	$1,602.00
Rate for Payer: United Healthcare Commercial	$978.38

2cmx3cm THIN GRAFT

Facility

$2,070.00

Service Code	HCPCS C1713
Hospital Charge Code	8781513
Hospital Revenue Code	278
Min. Negotiated Rate	$931.50
Max. Negotiated Rate	$1,863.00
Rate for Payer: Aetna of IA Commercial	$1,863.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,863.00
Rate for Payer: Aetna of IA Medicare	$1,179.90
Rate for Payer: Amerigroup Medicaid	$1,193.98
Rate for Payer: Amerigroup Medicare	$940.82
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,552.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$931.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,182.38
Rate for Payer: Medical Associates Commercial	$1,552.50
Rate for Payer: Medical Associates Managed Medicare	$931.50
Rate for Payer: Midlands Choice Commercial	$1,449.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,199.77
Rate for Payer: Partners Health Alliance Commercial	$1,071.22
Rate for Payer: United Healthcare Commercial	$1,863.00
Rate for Payer: United Healthcare Managed Medicare	$1,221.30

Know your out-of-pocket cost for care.

All Charges