Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX49MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026557
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX49MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026557
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX50MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026558
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX50MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026558
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX51MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026559
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX51MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026559
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX52MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026560
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX52MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026560
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX53MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026561
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX53MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026561
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX54MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026562
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX54MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026562
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX55MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026563
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX55MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026563
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX56MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026564
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX56MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026564
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX58MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026565
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX58MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026565
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX61MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026566
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX61MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026566
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX64MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026567
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.00
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Aetna of IA Medicare	$1,417.59
Rate for Payer: Amerigroup Medicaid	$1,255.19
Rate for Payer: Amerigroup Medicare	$1,255.94
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,243.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,243.00
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,243.50
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,262.15
Rate for Payer: Molina Healthcare Managed Medicare	$1,261.41
Rate for Payer: Oscar Health of IA Commercial	$1,865.25
Rate for Payer: Partners Health Alliance Commercial	$1,865.25
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX64MM

Facility

$2,487.00

Service Code	CPT L8699
Hospital Charge Code	8026567
Hospital Revenue Code	278
Min. Negotiated Rate	$1,740.90
Max. Negotiated Rate	$2,238.30
Rate for Payer: Aetna of IA Commercial	$2,238.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,238.30
Rate for Payer: Cash Price	$1,989.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,865.25
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: United Healthcare Commercial	$2,238.30

IMPLANT BIPOLAR COMP. UNIV HEAD 46X26

Facility

$2,438.00

Service Code	CPT L8699
Hospital Charge Code	8026553
Hospital Revenue Code	278
Min. Negotiated Rate	$1,706.60
Max. Negotiated Rate	$2,194.20
Rate for Payer: Aetna of IA Commercial	$2,194.20
Rate for Payer: Aetna of IA Medical Rental Products	$2,194.20
Rate for Payer: Cash Price	$1,950.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,828.50
Rate for Payer: Medical Associates Commercial	$1,828.50
Rate for Payer: Midlands Choice Commercial	$1,706.60
Rate for Payer: United Healthcare Commercial	$2,194.20

IMPLANT BIPOLAR COMP. UNIV HEAD 46X26

Facility

$2,438.00

Service Code	CPT L8699
Hospital Charge Code	8026553
Hospital Revenue Code	278
Min. Negotiated Rate	$1,218.51
Max. Negotiated Rate	$2,194.20
Rate for Payer: Aetna of IA Commercial	$2,194.20
Rate for Payer: Aetna of IA Medical Rental Products	$2,194.20
Rate for Payer: Aetna of IA Medicare	$1,389.66
Rate for Payer: Amerigroup Medicaid	$1,230.46
Rate for Payer: Amerigroup Medicare	$1,231.19
Rate for Payer: Cash Price	$1,950.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,828.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,219.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,218.51
Rate for Payer: Medical Associates Commercial	$1,828.50
Rate for Payer: Medical Associates Managed Medicare	$1,219.00
Rate for Payer: Midlands Choice Commercial	$1,706.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1,237.28
Rate for Payer: Molina Healthcare Managed Medicare	$1,236.55
Rate for Payer: Oscar Health of IA Commercial	$1,828.50
Rate for Payer: Partners Health Alliance Commercial	$1,828.50
Rate for Payer: United Healthcare Commercial	$2,194.20
Rate for Payer: United Healthcare Managed Medicare	$1,438.42

IMPLANT CABLE PLUG 5.0

Facility

$68.00

Service Code	CPT C1713
Hospital Charge Code	8046632
Hospital Revenue Code	278
Min. Negotiated Rate	$33.99
Max. Negotiated Rate	$61.20
Rate for Payer: Aetna of IA Commercial	$61.20
Rate for Payer: Aetna of IA Medical Rental Products	$61.20
Rate for Payer: Aetna of IA Medicare	$38.76
Rate for Payer: Amerigroup Medicaid	$34.32
Rate for Payer: Amerigroup Medicare	$34.34
Rate for Payer: Cash Price	$54.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$51.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$34.00
Rate for Payer: Iowa Total Care Managed Medicaid	$33.99
Rate for Payer: Medical Associates Commercial	$51.00
Rate for Payer: Medical Associates Managed Medicare	$34.00
Rate for Payer: Midlands Choice Commercial	$47.60
Rate for Payer: Molina Healthcare Managed Medicaid	$34.51
Rate for Payer: Molina Healthcare Managed Medicare	$34.49
Rate for Payer: Oscar Health of IA Commercial	$51.00
Rate for Payer: Partners Health Alliance Commercial	$51.00
Rate for Payer: United Healthcare Commercial	$61.20
Rate for Payer: United Healthcare Managed Medicare	$40.12

Know your out-of-pocket cost for care.

All Charges