Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

APPL SKIN SUB < 100 1ST 25 CM LEG/ANKLE

Facility

$711.00

Service Code	CPT 15271
Hospital Charge Code	7438782
Hospital Revenue Code	510
Min. Negotiated Rate	$497.70
Max. Negotiated Rate	$639.90
Rate for Payer: Aetna of IA Commercial	$639.90
Rate for Payer: Aetna of IA Medical Rental Products	$639.90
Rate for Payer: Cash Price	$568.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$533.25
Rate for Payer: Medical Associates Commercial	$533.25
Rate for Payer: Midlands Choice Commercial	$497.70
Rate for Payer: United Healthcare Commercial	$639.90

APPL SKIN SUB 1ST 100 SQ CM FEET/TOES

Facility

$824.00

Service Code	CPT 15277
Hospital Charge Code	8013705
Hospital Revenue Code	510
Min. Negotiated Rate	$576.80
Max. Negotiated Rate	$741.60
Rate for Payer: Aetna of IA Commercial	$741.60
Rate for Payer: Aetna of IA Medical Rental Products	$741.60
Rate for Payer: Cash Price	$659.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$618.00
Rate for Payer: Medical Associates Commercial	$618.00
Rate for Payer: Midlands Choice Commercial	$576.80
Rate for Payer: United Healthcare Commercial	$741.60

APPL SKIN SUB 1ST 100 SQ CM FEET/TOES

Facility

$824.00

Service Code	CPT 15277
Hospital Charge Code	8013705
Hospital Revenue Code	510
Min. Negotiated Rate	$370.80
Max. Negotiated Rate	$3,434.06
Rate for Payer: Aetna of IA Commercial	$741.60
Rate for Payer: Aetna of IA Medical Rental Products	$741.60
Rate for Payer: Aetna of IA Medicare	$469.68
Rate for Payer: Amerigroup Medicaid	$475.28
Rate for Payer: Amerigroup Medicare	$374.51
Rate for Payer: Cash Price	$659.20
Rate for Payer: Cash Price	$659.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$618.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$370.80
Rate for Payer: Iowa Total Care Managed Medicaid	$470.67
Rate for Payer: Medical Associates Commercial	$618.00
Rate for Payer: Medical Associates Managed Medicare	$370.80
Rate for Payer: Midlands Choice Commercial	$576.80
Rate for Payer: Molina Healthcare Managed Medicaid	$477.59
Rate for Payer: Partners Health Alliance Commercial	$426.42
Rate for Payer: United Healthcare Commercial	$741.60
Rate for Payer: United Healthcare Managed Medicare	$486.16
Rate for Payer: Wellmark IA HMO WHPI	$3,117.47
Rate for Payer: Wellmark IA PPO	$3,434.06

APPL SKIN SUB 1ST 100 SQ CM LEG/ANKLE

Facility

$930.00

Service Code	CPT 15273
Hospital Charge Code	8013701
Hospital Revenue Code	510
Min. Negotiated Rate	$651.00
Max. Negotiated Rate	$837.00
Rate for Payer: Aetna of IA Commercial	$837.00
Rate for Payer: Aetna of IA Medical Rental Products	$837.00
Rate for Payer: Cash Price	$744.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$697.50
Rate for Payer: Medical Associates Commercial	$697.50
Rate for Payer: Midlands Choice Commercial	$651.00
Rate for Payer: United Healthcare Commercial	$837.00

APPL SKIN SUB 1ST 100 SQ CM LEG/ANKLE

Facility

$930.00

Service Code	CPT 15273
Hospital Charge Code	8013701
Hospital Revenue Code	510
Min. Negotiated Rate	$418.50
Max. Negotiated Rate	$3,434.06
Rate for Payer: Aetna of IA Commercial	$837.00
Rate for Payer: Aetna of IA Medical Rental Products	$837.00
Rate for Payer: Aetna of IA Medicare	$530.10
Rate for Payer: Amerigroup Medicaid	$536.42
Rate for Payer: Amerigroup Medicare	$422.68
Rate for Payer: Cash Price	$744.00
Rate for Payer: Cash Price	$744.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$697.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$418.50
Rate for Payer: Iowa Total Care Managed Medicaid	$531.22
Rate for Payer: Medical Associates Commercial	$697.50
Rate for Payer: Medical Associates Managed Medicare	$418.50
Rate for Payer: Midlands Choice Commercial	$651.00
Rate for Payer: Molina Healthcare Managed Medicaid	$539.03
Rate for Payer: Partners Health Alliance Commercial	$481.28
Rate for Payer: United Healthcare Commercial	$837.00
Rate for Payer: United Healthcare Managed Medicare	$548.70
Rate for Payer: Wellmark IA HMO WHPI	$3,117.47
Rate for Payer: Wellmark IA PPO	$3,434.06

APPL SKIN SUB EA ADD 100 SQ CM FEET/TOES

Facility

$507.00

Service Code	CPT 15278
Hospital Charge Code	8013706
Hospital Revenue Code	510
Min. Negotiated Rate	$228.15
Max. Negotiated Rate	$3,434.06
Rate for Payer: Aetna of IA Commercial	$456.30
Rate for Payer: Aetna of IA Medical Rental Products	$456.30
Rate for Payer: Aetna of IA Medicare	$288.99
Rate for Payer: Amerigroup Medicaid	$292.44
Rate for Payer: Amerigroup Medicare	$230.43
Rate for Payer: Cash Price	$405.60
Rate for Payer: Cash Price	$405.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$380.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$228.15
Rate for Payer: Iowa Total Care Managed Medicaid	$289.60
Rate for Payer: Medical Associates Commercial	$380.25
Rate for Payer: Medical Associates Managed Medicare	$228.15
Rate for Payer: Midlands Choice Commercial	$354.90
Rate for Payer: Molina Healthcare Managed Medicaid	$293.86
Rate for Payer: Partners Health Alliance Commercial	$262.37
Rate for Payer: United Healthcare Commercial	$456.30
Rate for Payer: United Healthcare Managed Medicare	$299.13
Rate for Payer: Wellmark IA HMO WHPI	$3,117.47
Rate for Payer: Wellmark IA PPO	$3,434.06

APPL SKIN SUB EA ADD 100 SQ CM FEET/TOES

Facility

$507.00

Service Code	CPT 15278
Hospital Charge Code	8013706
Hospital Revenue Code	510
Min. Negotiated Rate	$354.90
Max. Negotiated Rate	$456.30
Rate for Payer: Aetna of IA Commercial	$456.30
Rate for Payer: Aetna of IA Medical Rental Products	$456.30
Rate for Payer: Cash Price	$405.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$380.25
Rate for Payer: Medical Associates Commercial	$380.25
Rate for Payer: Midlands Choice Commercial	$354.90
Rate for Payer: United Healthcare Commercial	$456.30

APPL SKIN SUB EA ADD 100 SQ CM LEG/ANKLE

Facility

$78.00

Service Code	CPT 15274
Hospital Charge Code	8013702
Hospital Revenue Code	510
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of IA Commercial	$70.20
Rate for Payer: Aetna of IA Medical Rental Products	$70.20
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.50
Rate for Payer: Medical Associates Commercial	$58.50
Rate for Payer: Midlands Choice Commercial	$54.60
Rate for Payer: United Healthcare Commercial	$70.20

APPL SKIN SUB EA ADD 100 SQ CM LEG/ANKLE

Facility

$78.00

Service Code	CPT 15274
Hospital Charge Code	8013702
Hospital Revenue Code	510
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$3,434.06
Rate for Payer: Aetna of IA Commercial	$70.20
Rate for Payer: Aetna of IA Medical Rental Products	$70.20
Rate for Payer: Aetna of IA Medicare	$44.46
Rate for Payer: Amerigroup Medicaid	$44.99
Rate for Payer: Amerigroup Medicare	$35.45
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$35.10
Rate for Payer: Iowa Total Care Managed Medicaid	$44.55
Rate for Payer: Medical Associates Commercial	$58.50
Rate for Payer: Medical Associates Managed Medicare	$35.10
Rate for Payer: Midlands Choice Commercial	$54.60
Rate for Payer: Molina Healthcare Managed Medicaid	$45.21
Rate for Payer: Partners Health Alliance Commercial	$40.36
Rate for Payer: United Healthcare Commercial	$70.20
Rate for Payer: United Healthcare Managed Medicare	$46.02
Rate for Payer: Wellmark IA HMO WHPI	$3,117.47
Rate for Payer: Wellmark IA PPO	$3,434.06

APPL SKIN SUB EA ADD 1ST 25 CM FEET/TOES

Facility

$173.00

Service Code	CPT 15276
Hospital Charge Code	8013704
Hospital Revenue Code	510
Min. Negotiated Rate	$77.85
Max. Negotiated Rate	$3,434.06
Rate for Payer: Aetna of IA Commercial	$155.70
Rate for Payer: Aetna of IA Medical Rental Products	$155.70
Rate for Payer: Aetna of IA Medicare	$98.61
Rate for Payer: Amerigroup Medicaid	$99.79
Rate for Payer: Amerigroup Medicare	$78.63
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cash Price	$138.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$129.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$77.85
Rate for Payer: Iowa Total Care Managed Medicaid	$98.82
Rate for Payer: Medical Associates Commercial	$129.75
Rate for Payer: Medical Associates Managed Medicare	$77.85
Rate for Payer: Midlands Choice Commercial	$121.10
Rate for Payer: Molina Healthcare Managed Medicaid	$100.27
Rate for Payer: Partners Health Alliance Commercial	$89.53
Rate for Payer: United Healthcare Commercial	$155.70
Rate for Payer: United Healthcare Managed Medicare	$102.07
Rate for Payer: Wellmark IA HMO WHPI	$3,117.47
Rate for Payer: Wellmark IA PPO	$3,434.06

APPL SKIN SUB EA ADD 1ST 25 CM FEET/TOES

Facility

$173.00

Service Code	CPT 15276
Hospital Charge Code	8013704
Hospital Revenue Code	510
Min. Negotiated Rate	$121.10
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of IA Commercial	$155.70
Rate for Payer: Aetna of IA Medical Rental Products	$155.70
Rate for Payer: Cash Price	$138.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$129.75
Rate for Payer: Medical Associates Commercial	$129.75
Rate for Payer: Midlands Choice Commercial	$121.10
Rate for Payer: United Healthcare Commercial	$155.70

APPL SKIN SUB EA ADD 1ST 25 CM LEG/ANKLE

Facility

$1,357.00

Service Code	CPT 15272
Hospital Charge Code	7440782
Hospital Revenue Code	510
Min. Negotiated Rate	$610.65
Max. Negotiated Rate	$3,434.06
Rate for Payer: Aetna of IA Commercial	$1,221.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,221.30
Rate for Payer: Aetna of IA Medicare	$773.49
Rate for Payer: Amerigroup Medicaid	$782.72
Rate for Payer: Amerigroup Medicare	$616.76
Rate for Payer: Cash Price	$1,085.60
Rate for Payer: Cash Price	$1,085.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,017.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$610.65
Rate for Payer: Iowa Total Care Managed Medicaid	$775.12
Rate for Payer: Medical Associates Commercial	$1,017.75
Rate for Payer: Medical Associates Managed Medicare	$610.65
Rate for Payer: Midlands Choice Commercial	$949.90
Rate for Payer: Molina Healthcare Managed Medicaid	$786.52
Rate for Payer: Partners Health Alliance Commercial	$702.25
Rate for Payer: United Healthcare Commercial	$1,221.30
Rate for Payer: United Healthcare Managed Medicare	$800.63
Rate for Payer: Wellmark IA HMO WHPI	$3,117.47
Rate for Payer: Wellmark IA PPO	$3,434.06

APPL SKIN SUB EA ADD 1ST 25 CM LEG/ANKLE

Facility

$1,357.00

Service Code	CPT 15272
Hospital Charge Code	7440782
Hospital Revenue Code	510
Min. Negotiated Rate	$949.90
Max. Negotiated Rate	$1,221.30
Rate for Payer: Aetna of IA Commercial	$1,221.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,221.30
Rate for Payer: Cash Price	$1,085.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,017.75
Rate for Payer: Medical Associates Commercial	$1,017.75
Rate for Payer: Midlands Choice Commercial	$949.90
Rate for Payer: United Healthcare Commercial	$1,221.30

APPLY FOREARM SPLINT

Facility

$241.00

Service Code	CPT 29125
Hospital Charge Code	4864883
Hospital Revenue Code	450
Min. Negotiated Rate	$102.81
Max. Negotiated Rate	$216.90
Rate for Payer: Aetna of IA Commercial	$216.90
Rate for Payer: Aetna of IA Medical Rental Products	$216.90
Rate for Payer: Aetna of IA Medicare	$137.37
Rate for Payer: Amerigroup Medicaid	$139.01
Rate for Payer: Amerigroup Medicare	$109.53
Rate for Payer: Cash Price	$192.80
Rate for Payer: Cash Price	$192.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$180.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$108.45
Rate for Payer: Iowa Total Care Managed Medicaid	$137.66
Rate for Payer: Medical Associates Commercial	$180.75
Rate for Payer: Medical Associates Managed Medicare	$108.45
Rate for Payer: Midlands Choice Commercial	$168.70
Rate for Payer: Molina Healthcare Managed Medicaid	$139.68
Rate for Payer: Partners Health Alliance Commercial	$124.72
Rate for Payer: United Healthcare Commercial	$216.90
Rate for Payer: United Healthcare Managed Medicare	$142.19
Rate for Payer: Wellmark IA HMO WHPI	$102.81
Rate for Payer: Wellmark IA PPO	$113.25

APPLY FOREARM SPLINT

Facility

$241.00

Service Code	CPT 29125
Hospital Charge Code	4864883
Hospital Revenue Code	450
Min. Negotiated Rate	$168.70
Max. Negotiated Rate	$216.90
Rate for Payer: Aetna of IA Commercial	$216.90
Rate for Payer: Aetna of IA Medical Rental Products	$216.90
Rate for Payer: Cash Price	$192.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$180.75
Rate for Payer: Medical Associates Commercial	$180.75
Rate for Payer: Midlands Choice Commercial	$168.70
Rate for Payer: United Healthcare Commercial	$216.90

APPLY FOREARM SPLINT

Professional

Both

$168.00

Service Code	CPT 29125
Hospital Charge Code	7982789
Hospital Revenue Code	981
Min. Negotiated Rate	$68.17
Max. Negotiated Rate	$151.70
Rate for Payer: Amerigroup Medicaid	$68.83
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Iowa Total Care Managed Medicaid	$68.17
Rate for Payer: Medical Associates Commercial	$126.00
Rate for Payer: Midlands Choice Commercial	$117.60
Rate for Payer: Molina Healthcare Managed Medicaid	$68.50
Rate for Payer: Partners Health Alliance Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$95.49
Rate for Payer: Wellmark IA HMO WHPI	$128.90
Rate for Payer: Wellmark IA PPO	$151.70

APPLY HAND/WRIST CAST

Facility

$160.00

Service Code	CPT 29085
Hospital Charge Code	4864880
Hospital Revenue Code	450
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of IA Commercial	$144.00
Rate for Payer: Aetna of IA Medical Rental Products	$144.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.00
Rate for Payer: Medical Associates Commercial	$120.00
Rate for Payer: Midlands Choice Commercial	$112.00
Rate for Payer: United Healthcare Commercial	$144.00

APPLY HAND/WRIST CAST

Facility

$160.00

Service Code	CPT 29085
Hospital Charge Code	4864880
Hospital Revenue Code	450
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$499.84
Rate for Payer: Aetna of IA Commercial	$144.00
Rate for Payer: Aetna of IA Medical Rental Products	$144.00
Rate for Payer: Aetna of IA Medicare	$91.20
Rate for Payer: Amerigroup Medicaid	$92.29
Rate for Payer: Amerigroup Medicare	$72.72
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$72.00
Rate for Payer: Iowa Total Care Managed Medicaid	$91.39
Rate for Payer: Medical Associates Commercial	$120.00
Rate for Payer: Medical Associates Managed Medicare	$72.00
Rate for Payer: Midlands Choice Commercial	$112.00
Rate for Payer: Molina Healthcare Managed Medicaid	$92.74
Rate for Payer: Partners Health Alliance Commercial	$82.80
Rate for Payer: United Healthcare Commercial	$144.00
Rate for Payer: United Healthcare Managed Medicare	$94.40
Rate for Payer: Wellmark IA HMO WHPI	$453.76
Rate for Payer: Wellmark IA PPO	$499.84

APPLY LONG ARM SPLINT

Professional

Both

$221.00

Service Code	CPT 29105
Hospital Charge Code	7982790
Hospital Revenue Code	981
Min. Negotiated Rate	$89.05
Max. Negotiated Rate	$188.00
Rate for Payer: Amerigroup Medicaid	$89.92
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cash Price	$176.80
Rate for Payer: Iowa Total Care Managed Medicaid	$89.05
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: Molina Healthcare Managed Medicaid	$89.48
Rate for Payer: Partners Health Alliance Commercial	$165.75
Rate for Payer: United Healthcare Commercial	$121.65
Rate for Payer: Wellmark IA HMO WHPI	$159.80
Rate for Payer: Wellmark IA PPO	$188.00

APPLY LONG ARM SPLINT

Professional

Both

$146.00

Service Code	CPT 29105
Hospital Charge Code	8799152
Hospital Revenue Code	975
Min. Negotiated Rate	$89.05
Max. Negotiated Rate	$188.00
Rate for Payer: Amerigroup Medicaid	$89.92
Rate for Payer: Cash Price	$116.80
Rate for Payer: Cash Price	$116.80
Rate for Payer: Iowa Total Care Managed Medicaid	$89.05
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: Molina Healthcare Managed Medicaid	$89.48
Rate for Payer: Partners Health Alliance Commercial	$109.50
Rate for Payer: United Healthcare Commercial	$121.65
Rate for Payer: Wellmark IA HMO WHPI	$159.80
Rate for Payer: Wellmark IA PPO	$188.00

APPLY LONG ARM SPLINT

Facility

$247.00

Service Code	CPT 29105
Hospital Charge Code	4864882
Hospital Revenue Code	450
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$222.30
Rate for Payer: Aetna of IA Commercial	$222.30
Rate for Payer: Aetna of IA Medical Rental Products	$222.30
Rate for Payer: Cash Price	$197.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$185.25
Rate for Payer: Medical Associates Commercial	$185.25
Rate for Payer: Midlands Choice Commercial	$172.90
Rate for Payer: United Healthcare Commercial	$222.30

APPLY LONG ARM SPLINT

Facility

$247.00

Service Code	CPT 29105
Hospital Charge Code	4864882
Hospital Revenue Code	450
Min. Negotiated Rate	$102.81
Max. Negotiated Rate	$222.30
Rate for Payer: Aetna of IA Commercial	$222.30
Rate for Payer: Aetna of IA Medical Rental Products	$222.30
Rate for Payer: Aetna of IA Medicare	$140.79
Rate for Payer: Amerigroup Medicaid	$142.47
Rate for Payer: Amerigroup Medicare	$112.26
Rate for Payer: Cash Price	$197.60
Rate for Payer: Cash Price	$197.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$185.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$111.15
Rate for Payer: Iowa Total Care Managed Medicaid	$141.09
Rate for Payer: Medical Associates Commercial	$185.25
Rate for Payer: Medical Associates Managed Medicare	$111.15
Rate for Payer: Midlands Choice Commercial	$172.90
Rate for Payer: Molina Healthcare Managed Medicaid	$143.16
Rate for Payer: Partners Health Alliance Commercial	$127.82
Rate for Payer: United Healthcare Commercial	$222.30
Rate for Payer: United Healthcare Managed Medicare	$145.73
Rate for Payer: Wellmark IA HMO WHPI	$102.81
Rate for Payer: Wellmark IA PPO	$113.25

APPLY LONG LEG CAST BRACE

Facility

$229.00

Service Code	CPT 29358
Hospital Charge Code	7983050
Hospital Revenue Code	450
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of IA Commercial	$206.10
Rate for Payer: Aetna of IA Medical Rental Products	$206.10
Rate for Payer: Cash Price	$183.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.75
Rate for Payer: Medical Associates Commercial	$171.75
Rate for Payer: Midlands Choice Commercial	$160.30
Rate for Payer: United Healthcare Commercial	$206.10

APPLY LONG LEG CAST BRACE

Professional

Both

$535.00

Service Code	CPT 29358
Hospital Charge Code	7982864
Hospital Revenue Code	981
Min. Negotiated Rate	$186.11
Max. Negotiated Rate	$401.25
Rate for Payer: Amerigroup Medicaid	$187.93
Rate for Payer: Cash Price	$428.00
Rate for Payer: Cash Price	$428.00
Rate for Payer: Iowa Total Care Managed Medicaid	$186.11
Rate for Payer: Medical Associates Commercial	$401.25
Rate for Payer: Midlands Choice Commercial	$374.50
Rate for Payer: Molina Healthcare Managed Medicaid	$187.02
Rate for Payer: Partners Health Alliance Commercial	$401.25
Rate for Payer: United Healthcare Commercial	$236.08
Rate for Payer: Wellmark IA HMO WHPI	$313.20
Rate for Payer: Wellmark IA PPO	$368.50

APPLY LONG LEG CAST BRACE

Facility

$229.00

Service Code	CPT 29358
Hospital Charge Code	7983050
Hospital Revenue Code	450
Min. Negotiated Rate	$103.05
Max. Negotiated Rate	$499.84
Rate for Payer: Aetna of IA Commercial	$206.10
Rate for Payer: Aetna of IA Medical Rental Products	$206.10
Rate for Payer: Aetna of IA Medicare	$130.53
Rate for Payer: Amerigroup Medicaid	$132.09
Rate for Payer: Amerigroup Medicare	$104.08
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cash Price	$183.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.05
Rate for Payer: Iowa Total Care Managed Medicaid	$130.80
Rate for Payer: Medical Associates Commercial	$171.75
Rate for Payer: Medical Associates Managed Medicare	$103.05
Rate for Payer: Midlands Choice Commercial	$160.30
Rate for Payer: Molina Healthcare Managed Medicaid	$132.73
Rate for Payer: Partners Health Alliance Commercial	$118.51
Rate for Payer: United Healthcare Commercial	$206.10
Rate for Payer: United Healthcare Managed Medicare	$135.11
Rate for Payer: Wellmark IA HMO WHPI	$453.76
Rate for Payer: Wellmark IA PPO	$499.84

Know your out-of-pocket cost for care.

All Charges