Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

RECOVERY PHASE 2: Per Interval (1 Qty)

Facility

$2.00

Hospital Charge Code	8397988
Hospital Revenue Code	710
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of IA Commercial	$1.80
Rate for Payer: Aetna of IA Medical Rental Products	$1.80
Rate for Payer: Cash Price	$1.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.50
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: United Healthcare Commercial	$1.80

RECOVERY PHASE 2: Per Interval (1 Qty)

Facility

$2.00

Hospital Charge Code	8397988
Hospital Revenue Code	710
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of IA Commercial	$1.80
Rate for Payer: Aetna of IA Medical Rental Products	$1.80
Rate for Payer: Aetna of IA Medicare	$1.14
Rate for Payer: Amerigroup Medicaid	$1.15
Rate for Payer: Amerigroup Medicare	$0.91
Rate for Payer: Cash Price	$1.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.90
Rate for Payer: Iowa Total Care Managed Medicaid	$1.14
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Medical Associates Managed Medicare	$0.90
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1.16
Rate for Payer: Partners Health Alliance Commercial	$1.03
Rate for Payer: United Healthcare Commercial	$1.80
Rate for Payer: United Healthcare Managed Medicare	$1.18

RECTUM SURGERY PROCEDURE

Facility

$2,480.00

Service Code	CPT 45999
Hospital Charge Code	7982909
Hospital Revenue Code	450
Min. Negotiated Rate	$1,116.00
Max. Negotiated Rate	$2,232.00
Rate for Payer: Aetna of IA Commercial	$2,232.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,232.00
Rate for Payer: Aetna of IA Medicare	$1,413.60
Rate for Payer: Amerigroup Medicaid	$1,430.46
Rate for Payer: Amerigroup Medicare	$1,127.16
Rate for Payer: Cash Price	$1,984.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,860.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,116.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,416.58
Rate for Payer: Medical Associates Commercial	$1,860.00
Rate for Payer: Medical Associates Managed Medicare	$1,116.00
Rate for Payer: Midlands Choice Commercial	$1,736.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,437.41
Rate for Payer: Partners Health Alliance Commercial	$1,283.40
Rate for Payer: United Healthcare Commercial	$2,232.00
Rate for Payer: United Healthcare Managed Medicare	$1,463.20

RECTUM SURGERY PROCEDURE

Facility

$2,480.00

Service Code	CPT 45999
Hospital Charge Code	7982909
Hospital Revenue Code	450
Min. Negotiated Rate	$1,736.00
Max. Negotiated Rate	$2,232.00
Rate for Payer: Aetna of IA Commercial	$2,232.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,232.00
Rate for Payer: Cash Price	$1,984.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,860.00
Rate for Payer: Medical Associates Commercial	$1,860.00
Rate for Payer: Midlands Choice Commercial	$1,736.00
Rate for Payer: United Healthcare Commercial	$2,232.00

RE-EVALUATION OCC THERAPY

Facility

$156.00

Service Code	CPT 97168 GO
Hospital Charge Code	5520782
Hospital Revenue Code	434
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Aetna of IA Medicare	$88.92
Rate for Payer: Amerigroup Medicaid	$89.98
Rate for Payer: Amerigroup Medicare	$70.90
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$70.20
Rate for Payer: Iowa Total Care Managed Medicaid	$89.11
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Medical Associates Managed Medicare	$70.20
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: Molina Healthcare Managed Medicaid	$90.42
Rate for Payer: Partners Health Alliance Commercial	$80.73
Rate for Payer: United Healthcare Commercial	$140.40
Rate for Payer: United Healthcare Managed Medicare	$92.04

RE-EVALUATION OCC THERAPY

Facility

$156.00

Service Code	CPT 97168 GO
Hospital Charge Code	5520782
Hospital Revenue Code	434
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: United Healthcare Commercial	$140.40

regadenoson 0.4 mg/5 mL SD syringe [VDMC]

Facility

$86.24

Service Code	HCPCS J2785
Hospital Charge Code	10418813
Hospital Revenue Code	259
Min. Negotiated Rate	$60.37
Max. Negotiated Rate	$77.62
Rate for Payer: Aetna of IA Commercial	$77.62
Rate for Payer: Aetna of IA Medical Rental Products	$77.62
Rate for Payer: Cash Price	$68.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.68
Rate for Payer: Medical Associates Commercial	$64.68
Rate for Payer: Midlands Choice Commercial	$60.37
Rate for Payer: United Healthcare Commercial	$77.62

regadenoson 0.4 mg/5 mL SD syringe [VDMC]

Facility

$86.24

Service Code	HCPCS J2785
Hospital Charge Code	10418813
Hospital Revenue Code	259
Min. Negotiated Rate	$38.81
Max. Negotiated Rate	$77.62
Rate for Payer: Aetna of IA Commercial	$77.62
Rate for Payer: Aetna of IA Medical Rental Products	$77.62
Rate for Payer: Aetna of IA Medicare	$49.16
Rate for Payer: Amerigroup Medicaid	$49.74
Rate for Payer: Amerigroup Medicare	$39.20
Rate for Payer: Cash Price	$68.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.81
Rate for Payer: Iowa Total Care Managed Medicaid	$49.26
Rate for Payer: Medical Associates Commercial	$64.68
Rate for Payer: Medical Associates Managed Medicare	$38.81
Rate for Payer: Midlands Choice Commercial	$60.37
Rate for Payer: Molina Healthcare Managed Medicaid	$49.98
Rate for Payer: Partners Health Alliance Commercial	$44.63
Rate for Payer: United Healthcare Commercial	$77.62
Rate for Payer: United Healthcare Managed Medicare	$50.88

remdesivir 100 mg SDV Pow [VDMC]

Facility

$1,369.70

Service Code	HCPCS J0248
Hospital Charge Code	21102628
Hospital Revenue Code	250
Min. Negotiated Rate	$616.37
Max. Negotiated Rate	$1,232.73
Rate for Payer: Aetna of IA Commercial	$1,232.73
Rate for Payer: Aetna of IA Medical Rental Products	$1,232.73
Rate for Payer: Aetna of IA Medicare	$780.73
Rate for Payer: Amerigroup Medicaid	$790.04
Rate for Payer: Amerigroup Medicare	$622.53
Rate for Payer: Cash Price	$1,095.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,027.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$616.37
Rate for Payer: Iowa Total Care Managed Medicaid	$782.37
Rate for Payer: Medical Associates Commercial	$1,027.28
Rate for Payer: Medical Associates Managed Medicare	$616.37
Rate for Payer: Midlands Choice Commercial	$958.79
Rate for Payer: Molina Healthcare Managed Medicaid	$793.88
Rate for Payer: Partners Health Alliance Commercial	$708.82
Rate for Payer: United Healthcare Commercial	$1,232.73
Rate for Payer: United Healthcare Managed Medicare	$808.12

remdesivir 100 mg SDV Pow [VDMC]

Facility

$1,369.70

Service Code	HCPCS J0248
Hospital Charge Code	21102628
Hospital Revenue Code	250
Min. Negotiated Rate	$958.79
Max. Negotiated Rate	$1,232.73
Rate for Payer: Aetna of IA Commercial	$1,232.73
Rate for Payer: Aetna of IA Medical Rental Products	$1,232.73
Rate for Payer: Cash Price	$1,095.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,027.28
Rate for Payer: Medical Associates Commercial	$1,027.28
Rate for Payer: Midlands Choice Commercial	$958.79
Rate for Payer: United Healthcare Commercial	$1,232.73

Remote Group Therapy

Facility

$221.00

Service Code	HCPCS C7903
Hospital Charge Code	8300866
Hospital Revenue Code	915
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: United Healthcare Commercial	$198.90

Remote Group Therapy

Facility

$221.00

Service Code	HCPCS C7903
Hospital Charge Code	8300866
Hospital Revenue Code	915
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Aetna of IA Medicare	$125.97
Rate for Payer: Amerigroup Medicaid	$127.47
Rate for Payer: Amerigroup Medicare	$100.44
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.45
Rate for Payer: Iowa Total Care Managed Medicaid	$126.24
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Medical Associates Managed Medicare	$99.45
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: Molina Healthcare Managed Medicaid	$128.09
Rate for Payer: Partners Health Alliance Commercial	$114.37
Rate for Payer: United Healthcare Commercial	$198.90

Remote Treatment of a Mental Health Disorder 15-29 min

Facility

$332.00

Service Code	HCPCS C7900
Hospital Charge Code	8945619
Hospital Revenue Code	914
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$298.80
Rate for Payer: Aetna of IA Commercial	$298.80
Rate for Payer: Aetna of IA Medical Rental Products	$298.80
Rate for Payer: Cash Price	$265.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.00
Rate for Payer: Medical Associates Commercial	$249.00
Rate for Payer: Midlands Choice Commercial	$232.40
Rate for Payer: United Healthcare Commercial	$298.80

Remote Treatment of a Mental Health Disorder 15-29 min

Facility

$332.00

Service Code	HCPCS C7900
Hospital Charge Code	8945619
Hospital Revenue Code	914
Min. Negotiated Rate	$149.40
Max. Negotiated Rate	$298.80
Rate for Payer: Aetna of IA Commercial	$298.80
Rate for Payer: Aetna of IA Medical Rental Products	$298.80
Rate for Payer: Aetna of IA Medicare	$189.24
Rate for Payer: Amerigroup Medicaid	$191.50
Rate for Payer: Amerigroup Medicare	$150.89
Rate for Payer: Cash Price	$265.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$149.40
Rate for Payer: Iowa Total Care Managed Medicaid	$189.64
Rate for Payer: Medical Associates Commercial	$249.00
Rate for Payer: Medical Associates Managed Medicare	$149.40
Rate for Payer: Midlands Choice Commercial	$232.40
Rate for Payer: Molina Healthcare Managed Medicaid	$192.43
Rate for Payer: Partners Health Alliance Commercial	$171.81
Rate for Payer: United Healthcare Commercial	$298.80

Remote Treatment of a Mental Health Disorder 30-60 min

Facility

$331.00

Service Code	HCPCS C7901
Hospital Charge Code	8945620
Hospital Revenue Code	914
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$297.90
Rate for Payer: Aetna of IA Commercial	$297.90
Rate for Payer: Aetna of IA Medical Rental Products	$297.90
Rate for Payer: Cash Price	$264.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$248.25
Rate for Payer: Medical Associates Commercial	$248.25
Rate for Payer: Midlands Choice Commercial	$231.70
Rate for Payer: United Healthcare Commercial	$297.90

Remote Treatment of a Mental Health Disorder 30-60 min

Facility

$331.00

Service Code	HCPCS C7901
Hospital Charge Code	8945620
Hospital Revenue Code	914
Min. Negotiated Rate	$148.95
Max. Negotiated Rate	$297.90
Rate for Payer: Aetna of IA Commercial	$297.90
Rate for Payer: Aetna of IA Medical Rental Products	$297.90
Rate for Payer: Aetna of IA Medicare	$188.67
Rate for Payer: Amerigroup Medicaid	$190.92
Rate for Payer: Amerigroup Medicare	$150.44
Rate for Payer: Cash Price	$264.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$248.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$148.95
Rate for Payer: Iowa Total Care Managed Medicaid	$189.07
Rate for Payer: Medical Associates Commercial	$248.25
Rate for Payer: Medical Associates Managed Medicare	$148.95
Rate for Payer: Midlands Choice Commercial	$231.70
Rate for Payer: Molina Healthcare Managed Medicaid	$191.85
Rate for Payer: Partners Health Alliance Commercial	$171.29
Rate for Payer: United Healthcare Commercial	$297.90

Remote Treatment of a Mental Health Disorder ADDTL 15 min

Facility

$221.00

Service Code	HCPCS C7902
Hospital Charge Code	8300865
Hospital Revenue Code	914
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Aetna of IA Medicare	$125.97
Rate for Payer: Amerigroup Medicaid	$127.47
Rate for Payer: Amerigroup Medicare	$100.44
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.45
Rate for Payer: Iowa Total Care Managed Medicaid	$126.24
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Medical Associates Managed Medicare	$99.45
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: Molina Healthcare Managed Medicaid	$128.09
Rate for Payer: Partners Health Alliance Commercial	$114.37
Rate for Payer: United Healthcare Commercial	$198.90

Remote Treatment of a Mental Health Disorder ADDTL 15 min

Facility

$221.00

Service Code	HCPCS C7902
Hospital Charge Code	8300865
Hospital Revenue Code	914
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: United Healthcare Commercial	$198.90

REMOVAL FOREIGN BODY FOOT SUBQ

Professional

Both

$868.00

Service Code	CPT 28190
Hospital Charge Code	8825540
Hospital Revenue Code	975
Min. Negotiated Rate	$385.70
Max. Negotiated Rate	$651.00
Rate for Payer: Cash Price	$694.40
Rate for Payer: Cash Price	$694.40
Rate for Payer: Medical Associates Commercial	$651.00
Rate for Payer: Midlands Choice Commercial	$607.60
Rate for Payer: Partners Health Alliance Commercial	$651.00
Rate for Payer: United Healthcare Commercial	$385.70

REMOVAL OF ANAL FISSURE

Facility

$1,894.00

Service Code	CPT 46200
Hospital Charge Code	7982946
Hospital Revenue Code	450
Min. Negotiated Rate	$1,325.80
Max. Negotiated Rate	$1,704.60
Rate for Payer: Aetna of IA Commercial	$1,704.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,704.60
Rate for Payer: Cash Price	$1,515.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,420.50
Rate for Payer: Medical Associates Commercial	$1,420.50
Rate for Payer: Midlands Choice Commercial	$1,325.80
Rate for Payer: United Healthcare Commercial	$1,704.60

REMOVAL OF ANAL FISSURE

Facility

$1,894.00

Service Code	CPT 46200
Hospital Charge Code	7982946
Hospital Revenue Code	450
Min. Negotiated Rate	$852.30
Max. Negotiated Rate	$1,704.60
Rate for Payer: Aetna of IA Commercial	$1,704.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,704.60
Rate for Payer: Aetna of IA Medicare	$1,079.58
Rate for Payer: Amerigroup Medicaid	$1,092.46
Rate for Payer: Amerigroup Medicare	$860.82
Rate for Payer: Cash Price	$1,515.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,420.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$852.30
Rate for Payer: Iowa Total Care Managed Medicaid	$1,081.85
Rate for Payer: Medical Associates Commercial	$1,420.50
Rate for Payer: Medical Associates Managed Medicare	$852.30
Rate for Payer: Midlands Choice Commercial	$1,325.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,097.76
Rate for Payer: Partners Health Alliance Commercial	$980.14
Rate for Payer: United Healthcare Commercial	$1,704.60
Rate for Payer: United Healthcare Managed Medicare	$1,117.46

REMOVAL OF BREAST LESION

Facility

$1,624.00

Service Code	CPT 19120
Hospital Charge Code	7982978
Hospital Revenue Code	450
Min. Negotiated Rate	$1,136.80
Max. Negotiated Rate	$1,461.60
Rate for Payer: Aetna of IA Commercial	$1,461.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,461.60
Rate for Payer: Cash Price	$1,299.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,218.00
Rate for Payer: Medical Associates Commercial	$1,218.00
Rate for Payer: Midlands Choice Commercial	$1,136.80
Rate for Payer: United Healthcare Commercial	$1,461.60

REMOVAL OF BREAST LESION

Facility

$1,624.00

Service Code	CPT 19120
Hospital Charge Code	7982978
Hospital Revenue Code	450
Min. Negotiated Rate	$730.80
Max. Negotiated Rate	$1,461.60
Rate for Payer: Aetna of IA Commercial	$1,461.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,461.60
Rate for Payer: Aetna of IA Medicare	$925.68
Rate for Payer: Amerigroup Medicaid	$936.72
Rate for Payer: Amerigroup Medicare	$738.11
Rate for Payer: Cash Price	$1,299.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,218.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$730.80
Rate for Payer: Iowa Total Care Managed Medicaid	$927.63
Rate for Payer: Medical Associates Commercial	$1,218.00
Rate for Payer: Medical Associates Managed Medicare	$730.80
Rate for Payer: Midlands Choice Commercial	$1,136.80
Rate for Payer: Molina Healthcare Managed Medicaid	$941.27
Rate for Payer: Partners Health Alliance Commercial	$840.42
Rate for Payer: United Healthcare Commercial	$1,461.60
Rate for Payer: United Healthcare Managed Medicare	$958.16

REMOVAL OF FOOT FOREIGN BODY

Facility

$652.00

Service Code	CPT 28190
Hospital Charge Code	4864831
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Aetna of IA Medicare	$371.64
Rate for Payer: Amerigroup Medicaid	$376.07
Rate for Payer: Amerigroup Medicare	$296.33
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$293.40
Rate for Payer: Iowa Total Care Managed Medicaid	$372.42
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Medical Associates Managed Medicare	$293.40
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: Molina Healthcare Managed Medicaid	$377.90
Rate for Payer: Partners Health Alliance Commercial	$337.41
Rate for Payer: United Healthcare Commercial	$586.80
Rate for Payer: United Healthcare Managed Medicare	$384.68

REMOVAL OF FOOT FOREIGN BODY

Facility

$652.00

Service Code	CPT 28190
Hospital Charge Code	4864831
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: United Healthcare Commercial	$586.80

Know your out-of-pocket cost for care.

All Charges