Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX54MM

Facility

$2,487.00

Service Code	HCPCS L8699
Hospital Charge Code	8026562
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.15
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	$1,434.50
Rate for Payer: Amerigroup Medicare	$1,130.34
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	$1,119.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1,420.57
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,119.15
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,441.47
Rate for Payer: Partners Health Alliance Commercial	$1,287.02
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	HCPCS 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	HCPCS L8699
Hospital Charge Code	8026563
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.15
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	$1,434.50
Rate for Payer: Amerigroup Medicare	$1,130.34
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	$1,119.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1,420.57
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,119.15
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,441.47
Rate for Payer: Partners Health Alliance Commercial	$1,287.02
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	HCPCS 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	HCPCS L8699
Hospital Charge Code	8026564
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.15
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	$1,434.50
Rate for Payer: Amerigroup Medicare	$1,130.34
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	$1,119.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1,420.57
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,119.15
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,441.47
Rate for Payer: Partners Health Alliance Commercial	$1,287.02
Rate for Payer: United Healthcare Commercial	$2,238.30
Rate for Payer: United Healthcare Managed Medicare	$1,467.33

IMPLANT BIPOLAR COMP UNIV HEAD 28MMX56MM

Facility

$2,487.00

Service Code	HCPCS 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 28MMX58MM

Facility

$2,487.00

Service Code	HCPCS L8699
Hospital Charge Code	8026565
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.15
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	$1,434.50
Rate for Payer: Amerigroup Medicare	$1,130.34
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	$1,119.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1,420.57
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,119.15
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,441.47
Rate for Payer: Partners Health Alliance Commercial	$1,287.02
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	HCPCS 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 28MMX61MM

Facility

$2,487.00

Service Code	HCPCS L8699
Hospital Charge Code	8026566
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.15
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	$1,434.50
Rate for Payer: Amerigroup Medicare	$1,130.34
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	$1,119.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1,420.57
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,119.15
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,441.47
Rate for Payer: Partners Health Alliance Commercial	$1,287.02
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	HCPCS 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	HCPCS L8699
Hospital Charge Code	8026567
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.15
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	$1,434.50
Rate for Payer: Amerigroup Medicare	$1,130.34
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	$1,119.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1,420.57
Rate for Payer: Medical Associates Commercial	$1,865.25
Rate for Payer: Medical Associates Managed Medicare	$1,119.15
Rate for Payer: Midlands Choice Commercial	$1,740.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,441.47
Rate for Payer: Partners Health Alliance Commercial	$1,287.02
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	HCPCS 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	HCPCS L8699
Hospital Charge Code	8026553
Hospital Revenue Code	278
Min. Negotiated Rate	$1,097.10
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	$1,406.24
Rate for Payer: Amerigroup Medicare	$1,108.07
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	$1,097.10
Rate for Payer: Iowa Total Care Managed Medicaid	$1,392.59
Rate for Payer: Medical Associates Commercial	$1,828.50
Rate for Payer: Medical Associates Managed Medicare	$1,097.10
Rate for Payer: Midlands Choice Commercial	$1,706.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1,413.06
Rate for Payer: Partners Health Alliance Commercial	$1,261.66
Rate for Payer: United Healthcare Commercial	$2,194.20
Rate for Payer: United Healthcare Managed Medicare	$1,438.42

IMPLANT BIPOLAR COMP. UNIV HEAD 46X26

Facility

$2,438.00

Service Code	HCPCS 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 CABLE PLUG 5.0

Facility

$68.00

Service Code	HCPCS C1713
Hospital Charge Code	8046632
Hospital Revenue Code	278
Min. Negotiated Rate	$47.60
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: Cash Price	$54.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$51.00
Rate for Payer: Medical Associates Commercial	$51.00
Rate for Payer: Midlands Choice Commercial	$47.60
Rate for Payer: United Healthcare Commercial	$61.20

IMPLANT CABLE PLUG 5.0

Facility

$68.00

Service Code	HCPCS C1713
Hospital Charge Code	8046632
Hospital Revenue Code	278
Min. Negotiated Rate	$30.60
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	$39.22
Rate for Payer: Amerigroup Medicare	$30.91
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	$30.60
Rate for Payer: Iowa Total Care Managed Medicaid	$38.84
Rate for Payer: Medical Associates Commercial	$51.00
Rate for Payer: Medical Associates Managed Medicare	$30.60
Rate for Payer: Midlands Choice Commercial	$47.60
Rate for Payer: Molina Healthcare Managed Medicaid	$39.41
Rate for Payer: Partners Health Alliance Commercial	$35.19
Rate for Payer: United Healthcare Commercial	$61.20
Rate for Payer: United Healthcare Managed Medicare	$40.12

IMPLANT CANCELLOUS SCREW 6.5MM X 20MM

Facility

$293.00

Service Code	HCPCS C1713
Hospital Charge Code	8046802
Hospital Revenue Code	278
Min. Negotiated Rate	$205.10
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of IA Commercial	$263.70
Rate for Payer: Aetna of IA Medical Rental Products	$263.70
Rate for Payer: Cash Price	$234.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.75
Rate for Payer: Medical Associates Commercial	$219.75
Rate for Payer: Midlands Choice Commercial	$205.10
Rate for Payer: United Healthcare Commercial	$263.70

IMPLANT CANCELLOUS SCREW 6.5MM X 20MM

Facility

$293.00

Service Code	HCPCS C1713
Hospital Charge Code	8046802
Hospital Revenue Code	278
Min. Negotiated Rate	$131.85
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of IA Commercial	$263.70
Rate for Payer: Aetna of IA Medical Rental Products	$263.70
Rate for Payer: Aetna of IA Medicare	$167.01
Rate for Payer: Amerigroup Medicaid	$169.00
Rate for Payer: Amerigroup Medicare	$133.17
Rate for Payer: Cash Price	$234.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$131.85
Rate for Payer: Iowa Total Care Managed Medicaid	$167.36
Rate for Payer: Medical Associates Commercial	$219.75
Rate for Payer: Medical Associates Managed Medicare	$131.85
Rate for Payer: Midlands Choice Commercial	$205.10
Rate for Payer: Molina Healthcare Managed Medicaid	$169.82
Rate for Payer: Partners Health Alliance Commercial	$151.63
Rate for Payer: United Healthcare Commercial	$263.70
Rate for Payer: United Healthcare Managed Medicare	$172.87

IMPLANT CANCELLOUS SCREW 6.5MM X 24MM

Facility

$293.00

Service Code	HCPCS C1713
Hospital Charge Code	8046803
Hospital Revenue Code	278
Min. Negotiated Rate	$131.85
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of IA Commercial	$263.70
Rate for Payer: Aetna of IA Medical Rental Products	$263.70
Rate for Payer: Aetna of IA Medicare	$167.01
Rate for Payer: Amerigroup Medicaid	$169.00
Rate for Payer: Amerigroup Medicare	$133.17
Rate for Payer: Cash Price	$234.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$131.85
Rate for Payer: Iowa Total Care Managed Medicaid	$167.36
Rate for Payer: Medical Associates Commercial	$219.75
Rate for Payer: Medical Associates Managed Medicare	$131.85
Rate for Payer: Midlands Choice Commercial	$205.10
Rate for Payer: Molina Healthcare Managed Medicaid	$169.82
Rate for Payer: Partners Health Alliance Commercial	$151.63
Rate for Payer: United Healthcare Commercial	$263.70
Rate for Payer: United Healthcare Managed Medicare	$172.87

IMPLANT CANCELLOUS SCREW 6.5MM X 24MM

Facility

$293.00

Service Code	HCPCS C1713
Hospital Charge Code	8046803
Hospital Revenue Code	278
Min. Negotiated Rate	$205.10
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of IA Commercial	$263.70
Rate for Payer: Aetna of IA Medical Rental Products	$263.70
Rate for Payer: Cash Price	$234.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.75
Rate for Payer: Medical Associates Commercial	$219.75
Rate for Payer: Midlands Choice Commercial	$205.10
Rate for Payer: United Healthcare Commercial	$263.70

IMPLANT CANCELLOUS SCREW 6.5MM X 30MM

Facility

$293.00

Service Code	HCPCS C1713
Hospital Charge Code	8046804
Hospital Revenue Code	278
Min. Negotiated Rate	$131.85
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of IA Commercial	$263.70
Rate for Payer: Aetna of IA Medical Rental Products	$263.70
Rate for Payer: Aetna of IA Medicare	$167.01
Rate for Payer: Amerigroup Medicaid	$169.00
Rate for Payer: Amerigroup Medicare	$133.17
Rate for Payer: Cash Price	$234.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$131.85
Rate for Payer: Iowa Total Care Managed Medicaid	$167.36
Rate for Payer: Medical Associates Commercial	$219.75
Rate for Payer: Medical Associates Managed Medicare	$131.85
Rate for Payer: Midlands Choice Commercial	$205.10
Rate for Payer: Molina Healthcare Managed Medicaid	$169.82
Rate for Payer: Partners Health Alliance Commercial	$151.63
Rate for Payer: United Healthcare Commercial	$263.70
Rate for Payer: United Healthcare Managed Medicare	$172.87

IMPLANT CANCELLOUS SCREW 6.5MM X 30MM

Facility

$293.00

Service Code	HCPCS C1713
Hospital Charge Code	8046804
Hospital Revenue Code	278
Min. Negotiated Rate	$205.10
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of IA Commercial	$263.70
Rate for Payer: Aetna of IA Medical Rental Products	$263.70
Rate for Payer: Cash Price	$234.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.75
Rate for Payer: Medical Associates Commercial	$219.75
Rate for Payer: Midlands Choice Commercial	$205.10
Rate for Payer: United Healthcare Commercial	$263.70

IMPLANT CANCELLOUS SCREW 6.5MM X 35MM

Facility

$293.00

Service Code	HCPCS C1713
Hospital Charge Code	8046805
Hospital Revenue Code	278
Min. Negotiated Rate	$131.85
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of IA Commercial	$263.70
Rate for Payer: Aetna of IA Medical Rental Products	$263.70
Rate for Payer: Aetna of IA Medicare	$167.01
Rate for Payer: Amerigroup Medicaid	$169.00
Rate for Payer: Amerigroup Medicare	$133.17
Rate for Payer: Cash Price	$234.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$131.85
Rate for Payer: Iowa Total Care Managed Medicaid	$167.36
Rate for Payer: Medical Associates Commercial	$219.75
Rate for Payer: Medical Associates Managed Medicare	$131.85
Rate for Payer: Midlands Choice Commercial	$205.10
Rate for Payer: Molina Healthcare Managed Medicaid	$169.82
Rate for Payer: Partners Health Alliance Commercial	$151.63
Rate for Payer: United Healthcare Commercial	$263.70
Rate for Payer: United Healthcare Managed Medicare	$172.87

IMPLANT CANCELLOUS SCREW 6.5MM X 35MM

Facility

$293.00

Service Code	HCPCS C1713
Hospital Charge Code	8046805
Hospital Revenue Code	278
Min. Negotiated Rate	$205.10
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of IA Commercial	$263.70
Rate for Payer: Aetna of IA Medical Rental Products	$263.70
Rate for Payer: Cash Price	$234.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.75
Rate for Payer: Medical Associates Commercial	$219.75
Rate for Payer: Midlands Choice Commercial	$205.10
Rate for Payer: United Healthcare Commercial	$263.70

IMPLANT CEMENT SPACER

Facility

$292.00

Service Code	HCPCS C1769
Hospital Charge Code	8046309
Hospital Revenue Code	278
Min. Negotiated Rate	$131.40
Max. Negotiated Rate	$262.80
Rate for Payer: Aetna of IA Commercial	$262.80
Rate for Payer: Aetna of IA Medical Rental Products	$262.80
Rate for Payer: Aetna of IA Medicare	$166.44
Rate for Payer: Amerigroup Medicaid	$168.43
Rate for Payer: Amerigroup Medicare	$132.71
Rate for Payer: Cash Price	$233.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$219.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$131.40
Rate for Payer: Iowa Total Care Managed Medicaid	$166.79
Rate for Payer: Medical Associates Commercial	$219.00
Rate for Payer: Medical Associates Managed Medicare	$131.40
Rate for Payer: Midlands Choice Commercial	$204.40
Rate for Payer: Molina Healthcare Managed Medicaid	$169.24
Rate for Payer: Partners Health Alliance Commercial	$151.11
Rate for Payer: United Healthcare Commercial	$262.80
Rate for Payer: United Healthcare Managed Medicare	$172.28

Know your out-of-pocket cost for care.

All Charges