Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT INSERT TIBIAL SIZE #7 CS 13MM

Facility

$5,651.00

Service Code	CPT C1778
Hospital Charge Code	8026185
Hospital Revenue Code	278
Min. Negotiated Rate	$3,955.70
Max. Negotiated Rate	$5,085.90
Rate for Payer: Aetna of IA Commercial	$5,085.90
Rate for Payer: Aetna of IA Medical Rental Products	$5,085.90
Rate for Payer: Cash Price	$4,520.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,238.25
Rate for Payer: Medical Associates Commercial	$4,238.25
Rate for Payer: Midlands Choice Commercial	$3,955.70
Rate for Payer: United Healthcare Commercial	$5,085.90

IMPLANT INSERT TIBIAL SIZE #7 CS 13MM

Facility

$5,651.00

Service Code	CPT C1778
Hospital Charge Code	8026185
Hospital Revenue Code	278
Min. Negotiated Rate	$2,824.37
Max. Negotiated Rate	$5,085.90
Rate for Payer: Aetna of IA Commercial	$5,085.90
Rate for Payer: Aetna of IA Medical Rental Products	$5,085.90
Rate for Payer: Aetna of IA Medicare	$3,221.07
Rate for Payer: Amerigroup Medicaid	$2,852.06
Rate for Payer: Amerigroup Medicare	$2,853.76
Rate for Payer: Cash Price	$4,520.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,238.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,825.50
Rate for Payer: Iowa Total Care Managed Medicaid	$2,824.37
Rate for Payer: Medical Associates Commercial	$4,238.25
Rate for Payer: Medical Associates Managed Medicare	$2,825.50
Rate for Payer: Midlands Choice Commercial	$3,955.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,867.88
Rate for Payer: Molina Healthcare Managed Medicare	$2,866.19
Rate for Payer: Oscar Health of IA Commercial	$4,238.25
Rate for Payer: Partners Health Alliance Commercial	$4,238.25
Rate for Payer: United Healthcare Commercial	$5,085.90
Rate for Payer: United Healthcare Managed Medicare	$3,334.09

IMPLANT KNEE CRUCIATE RET FEMORAL SIZE 5

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046829
Hospital Revenue Code	278
Min. Negotiated Rate	$6,224.01
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Aetna of IA Medicare	$7,098.21
Rate for Payer: Amerigroup Medicaid	$6,285.03
Rate for Payer: Amerigroup Medicare	$6,288.76
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,226.50
Rate for Payer: Iowa Total Care Managed Medicaid	$6,224.01
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$6,226.50
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,319.90
Rate for Payer: Molina Healthcare Managed Medicare	$6,316.16
Rate for Payer: Oscar Health of IA Commercial	$9,339.75
Rate for Payer: Partners Health Alliance Commercial	$9,339.75
Rate for Payer: United Healthcare Commercial	$11,207.70
Rate for Payer: United Healthcare Managed Medicare	$7,347.27

IMPLANT KNEE CRUCIATE RET FEMORAL SIZE 5

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046829
Hospital Revenue Code	278
Min. Negotiated Rate	$8,717.10
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: United Healthcare Commercial	$11,207.70

IMPLANT KNEE CRUCIATE RET FEMORAL SIZE 6

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046830
Hospital Revenue Code	278
Min. Negotiated Rate	$6,224.01
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Aetna of IA Medicare	$7,098.21
Rate for Payer: Amerigroup Medicaid	$6,285.03
Rate for Payer: Amerigroup Medicare	$6,288.76
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,226.50
Rate for Payer: Iowa Total Care Managed Medicaid	$6,224.01
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$6,226.50
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,319.90
Rate for Payer: Molina Healthcare Managed Medicare	$6,316.16
Rate for Payer: Oscar Health of IA Commercial	$9,339.75
Rate for Payer: Partners Health Alliance Commercial	$9,339.75
Rate for Payer: United Healthcare Commercial	$11,207.70
Rate for Payer: United Healthcare Managed Medicare	$7,347.27

IMPLANT KNEE CRUCIATE RET FEMORAL SIZE 6

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046830
Hospital Revenue Code	278
Min. Negotiated Rate	$8,717.10
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: United Healthcare Commercial	$11,207.70

IMPLANT KNEE FEMORAL SIZE 4

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046827
Hospital Revenue Code	278
Min. Negotiated Rate	$6,224.01
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Aetna of IA Medicare	$7,098.21
Rate for Payer: Amerigroup Medicaid	$6,285.03
Rate for Payer: Amerigroup Medicare	$6,288.76
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,226.50
Rate for Payer: Iowa Total Care Managed Medicaid	$6,224.01
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$6,226.50
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,319.90
Rate for Payer: Molina Healthcare Managed Medicare	$6,316.16
Rate for Payer: Oscar Health of IA Commercial	$9,339.75
Rate for Payer: Partners Health Alliance Commercial	$9,339.75
Rate for Payer: United Healthcare Commercial	$11,207.70
Rate for Payer: United Healthcare Managed Medicare	$7,347.27

IMPLANT KNEE FEMORAL SIZE 4

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046827
Hospital Revenue Code	278
Min. Negotiated Rate	$8,717.10
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: United Healthcare Commercial	$11,207.70

IMPLANT KNEE FEMORAL SIZE 5

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046835
Hospital Revenue Code	278
Min. Negotiated Rate	$6,224.01
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Aetna of IA Medicare	$7,098.21
Rate for Payer: Amerigroup Medicaid	$6,285.03
Rate for Payer: Amerigroup Medicare	$6,288.76
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,226.50
Rate for Payer: Iowa Total Care Managed Medicaid	$6,224.01
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$6,226.50
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,319.90
Rate for Payer: Molina Healthcare Managed Medicare	$6,316.16
Rate for Payer: Oscar Health of IA Commercial	$9,339.75
Rate for Payer: Partners Health Alliance Commercial	$9,339.75
Rate for Payer: United Healthcare Commercial	$11,207.70
Rate for Payer: United Healthcare Managed Medicare	$7,347.27

IMPLANT KNEE FEMORAL SIZE 5

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046835
Hospital Revenue Code	278
Min. Negotiated Rate	$8,717.10
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: United Healthcare Commercial	$11,207.70

IMPLANT KNEE FEMORAL SIZE 6

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046831
Hospital Revenue Code	278
Min. Negotiated Rate	$6,224.01
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Aetna of IA Medicare	$7,098.21
Rate for Payer: Amerigroup Medicaid	$6,285.03
Rate for Payer: Amerigroup Medicare	$6,288.76
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,226.50
Rate for Payer: Iowa Total Care Managed Medicaid	$6,224.01
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$6,226.50
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,319.90
Rate for Payer: Molina Healthcare Managed Medicare	$6,316.16
Rate for Payer: Oscar Health of IA Commercial	$9,339.75
Rate for Payer: Partners Health Alliance Commercial	$9,339.75
Rate for Payer: United Healthcare Commercial	$11,207.70
Rate for Payer: United Healthcare Managed Medicare	$7,347.27

IMPLANT KNEE FEMORAL SIZE 6

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046831
Hospital Revenue Code	278
Min. Negotiated Rate	$8,717.10
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: United Healthcare Commercial	$11,207.70

IMPLANT KNEE FEMORAL SIZE 7

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046832
Hospital Revenue Code	278
Min. Negotiated Rate	$8,717.10
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: United Healthcare Commercial	$11,207.70

IMPLANT KNEE FEMORAL SIZE 7

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8046832
Hospital Revenue Code	278
Min. Negotiated Rate	$6,224.01
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Aetna of IA Medicare	$7,098.21
Rate for Payer: Amerigroup Medicaid	$6,285.03
Rate for Payer: Amerigroup Medicare	$6,288.76
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,226.50
Rate for Payer: Iowa Total Care Managed Medicaid	$6,224.01
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$6,226.50
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,319.90
Rate for Payer: Molina Healthcare Managed Medicare	$6,316.16
Rate for Payer: Oscar Health of IA Commercial	$9,339.75
Rate for Payer: Partners Health Alliance Commercial	$9,339.75
Rate for Payer: United Healthcare Commercial	$11,207.70
Rate for Payer: United Healthcare Managed Medicare	$7,347.27

IMPLANT KNEE FEMORAL SIZE 7 LFT

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8026179
Hospital Revenue Code	278
Min. Negotiated Rate	$6,224.01
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Aetna of IA Medicare	$7,098.21
Rate for Payer: Amerigroup Medicaid	$6,285.03
Rate for Payer: Amerigroup Medicare	$6,288.76
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,226.50
Rate for Payer: Iowa Total Care Managed Medicaid	$6,224.01
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$6,226.50
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,319.90
Rate for Payer: Molina Healthcare Managed Medicare	$6,316.16
Rate for Payer: Oscar Health of IA Commercial	$9,339.75
Rate for Payer: Partners Health Alliance Commercial	$9,339.75
Rate for Payer: United Healthcare Commercial	$11,207.70
Rate for Payer: United Healthcare Managed Medicare	$7,347.27

IMPLANT KNEE FEMORAL SIZE 7 LFT

Facility

$12,453.00

Service Code	CPT C1776
Hospital Charge Code	8026179
Hospital Revenue Code	278
Min. Negotiated Rate	$8,717.10
Max. Negotiated Rate	$11,207.70
Rate for Payer: Aetna of IA Commercial	$11,207.70
Rate for Payer: Aetna of IA Medical Rental Products	$11,207.70
Rate for Payer: Cash Price	$9,962.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,339.75
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: United Healthcare Commercial	$11,207.70

IMPLANT KNEE PATELLA A29

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8046880
Hospital Revenue Code	278
Min. Negotiated Rate	$2,090.20
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: United Healthcare Commercial	$2,687.40

IMPLANT KNEE PATELLA A29

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8046880
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.40
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Aetna of IA Medicare	$1,702.02
Rate for Payer: Amerigroup Medicaid	$1,507.03
Rate for Payer: Amerigroup Medicare	$1,507.93
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,493.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,492.40
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,493.00
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,515.40
Rate for Payer: Molina Healthcare Managed Medicare	$1,514.50
Rate for Payer: Oscar Health of IA Commercial	$2,239.50
Rate for Payer: Partners Health Alliance Commercial	$2,239.50
Rate for Payer: United Healthcare Commercial	$2,687.40
Rate for Payer: United Healthcare Managed Medicare	$1,761.74

IMPLANT KNEE PATELLA A32

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8046881
Hospital Revenue Code	278
Min. Negotiated Rate	$2,090.20
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: United Healthcare Commercial	$2,687.40

IMPLANT KNEE PATELLA A32

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8046881
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.40
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Aetna of IA Medicare	$1,702.02
Rate for Payer: Amerigroup Medicaid	$1,507.03
Rate for Payer: Amerigroup Medicare	$1,507.93
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,493.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,492.40
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,493.00
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,515.40
Rate for Payer: Molina Healthcare Managed Medicare	$1,514.50
Rate for Payer: Oscar Health of IA Commercial	$2,239.50
Rate for Payer: Partners Health Alliance Commercial	$2,239.50
Rate for Payer: United Healthcare Commercial	$2,687.40
Rate for Payer: United Healthcare Managed Medicare	$1,761.74

IMPLANT KNEE PATELLA A35

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8046882
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.40
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Aetna of IA Medicare	$1,702.02
Rate for Payer: Amerigroup Medicaid	$1,507.03
Rate for Payer: Amerigroup Medicare	$1,507.93
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,493.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,492.40
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,493.00
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,515.40
Rate for Payer: Molina Healthcare Managed Medicare	$1,514.50
Rate for Payer: Oscar Health of IA Commercial	$2,239.50
Rate for Payer: Partners Health Alliance Commercial	$2,239.50
Rate for Payer: United Healthcare Commercial	$2,687.40
Rate for Payer: United Healthcare Managed Medicare	$1,761.74

IMPLANT KNEE PATELLA A35

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8046882
Hospital Revenue Code	278
Min. Negotiated Rate	$2,090.20
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: United Healthcare Commercial	$2,687.40

IMPLANT KNEE PATELLA A38 11MM

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8026198
Hospital Revenue Code	278
Min. Negotiated Rate	$2,090.20
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: United Healthcare Commercial	$2,687.40

IMPLANT KNEE PATELLA A38 11MM

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8026198
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.40
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Aetna of IA Medicare	$1,702.02
Rate for Payer: Amerigroup Medicaid	$1,507.03
Rate for Payer: Amerigroup Medicare	$1,507.93
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,493.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,492.40
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,493.00
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,515.40
Rate for Payer: Molina Healthcare Managed Medicare	$1,514.50
Rate for Payer: Oscar Health of IA Commercial	$2,239.50
Rate for Payer: Partners Health Alliance Commercial	$2,239.50
Rate for Payer: United Healthcare Commercial	$2,687.40
Rate for Payer: United Healthcare Managed Medicare	$1,761.74

IMPLANT KNEE PATELLA A40 11MM

Facility

$2,986.00

Service Code	CPT C1776
Hospital Charge Code	8046883
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.40
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of IA Commercial	$2,687.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,687.40
Rate for Payer: Aetna of IA Medicare	$1,702.02
Rate for Payer: Amerigroup Medicaid	$1,507.03
Rate for Payer: Amerigroup Medicare	$1,507.93
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,239.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,493.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,492.40
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,493.00
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,515.40
Rate for Payer: Molina Healthcare Managed Medicare	$1,514.50
Rate for Payer: Oscar Health of IA Commercial	$2,239.50
Rate for Payer: Partners Health Alliance Commercial	$2,239.50
Rate for Payer: United Healthcare Commercial	$2,687.40
Rate for Payer: United Healthcare Managed Medicare	$1,761.74

Know your out-of-pocket cost for care.

All Charges