Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT KNEE FEMORAL SIZE 6

Facility

$12,453.00

Service Code	HCPCS C1776
Hospital Charge Code	8046831
Hospital Revenue Code	278
Min. Negotiated Rate	$5,603.85
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	$7,182.89
Rate for Payer: Amerigroup Medicare	$5,659.89
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	$5,603.85
Rate for Payer: Iowa Total Care Managed Medicaid	$7,113.15
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$5,603.85
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$7,217.76
Rate for Payer: Partners Health Alliance Commercial	$6,444.43
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	HCPCS 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	HCPCS 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	HCPCS C1776
Hospital Charge Code	8046832
Hospital Revenue Code	278
Min. Negotiated Rate	$5,603.85
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	$7,182.89
Rate for Payer: Amerigroup Medicare	$5,659.89
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	$5,603.85
Rate for Payer: Iowa Total Care Managed Medicaid	$7,113.15
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$5,603.85
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$7,217.76
Rate for Payer: Partners Health Alliance Commercial	$6,444.43
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	HCPCS C1776
Hospital Charge Code	8026179
Hospital Revenue Code	278
Min. Negotiated Rate	$5,603.85
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	$7,182.89
Rate for Payer: Amerigroup Medicare	$5,659.89
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	$5,603.85
Rate for Payer: Iowa Total Care Managed Medicaid	$7,113.15
Rate for Payer: Medical Associates Commercial	$9,339.75
Rate for Payer: Medical Associates Managed Medicare	$5,603.85
Rate for Payer: Midlands Choice Commercial	$8,717.10
Rate for Payer: Molina Healthcare Managed Medicaid	$7,217.76
Rate for Payer: Partners Health Alliance Commercial	$6,444.43
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	HCPCS 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	HCPCS C1776
Hospital Charge Code	8046880
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.70
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	$1,722.32
Rate for Payer: Amerigroup Medicare	$1,357.14
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	$1,343.70
Rate for Payer: Iowa Total Care Managed Medicaid	$1,705.60
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,343.70
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,730.69
Rate for Payer: Partners Health Alliance Commercial	$1,545.26
Rate for Payer: United Healthcare Commercial	$2,687.40
Rate for Payer: United Healthcare Managed Medicare	$1,761.74

IMPLANT KNEE PATELLA A29

Facility

$2,986.00

Service Code	HCPCS 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 A32

Facility

$2,986.00

Service Code	HCPCS 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	HCPCS C1776
Hospital Charge Code	8046881
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.70
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	$1,722.32
Rate for Payer: Amerigroup Medicare	$1,357.14
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	$1,343.70
Rate for Payer: Iowa Total Care Managed Medicaid	$1,705.60
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,343.70
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,730.69
Rate for Payer: Partners Health Alliance Commercial	$1,545.26
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	HCPCS 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 A35

Facility

$2,986.00

Service Code	HCPCS C1776
Hospital Charge Code	8046882
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.70
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	$1,722.32
Rate for Payer: Amerigroup Medicare	$1,357.14
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	$1,343.70
Rate for Payer: Iowa Total Care Managed Medicaid	$1,705.60
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,343.70
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,730.69
Rate for Payer: Partners Health Alliance Commercial	$1,545.26
Rate for Payer: United Healthcare Commercial	$2,687.40
Rate for Payer: United Healthcare Managed Medicare	$1,761.74

IMPLANT KNEE PATELLA A38 11MM

Facility

$2,986.00

Service Code	HCPCS 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	HCPCS C1776
Hospital Charge Code	8026198
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.70
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	$1,722.32
Rate for Payer: Amerigroup Medicare	$1,357.14
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	$1,343.70
Rate for Payer: Iowa Total Care Managed Medicaid	$1,705.60
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,343.70
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,730.69
Rate for Payer: Partners Health Alliance Commercial	$1,545.26
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	HCPCS C1776
Hospital Charge Code	8046883
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 A40 11MM

Facility

$2,986.00

Service Code	HCPCS C1776
Hospital Charge Code	8046883
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.70
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	$1,722.32
Rate for Payer: Amerigroup Medicare	$1,357.14
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	$1,343.70
Rate for Payer: Iowa Total Care Managed Medicaid	$1,705.60
Rate for Payer: Medical Associates Commercial	$2,239.50
Rate for Payer: Medical Associates Managed Medicare	$1,343.70
Rate for Payer: Midlands Choice Commercial	$2,090.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,730.69
Rate for Payer: Partners Health Alliance Commercial	$1,545.26
Rate for Payer: United Healthcare Commercial	$2,687.40
Rate for Payer: United Healthcare Managed Medicare	$1,761.74

IMPLANT KNEE TIBAL BASEPLATE #8

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8026181
Hospital Revenue Code	278
Min. Negotiated Rate	$3,601.80
Max. Negotiated Rate	$7,203.60
Rate for Payer: Aetna of IA Commercial	$7,203.60
Rate for Payer: Aetna of IA Medical Rental Products	$7,203.60
Rate for Payer: Aetna of IA Medicare	$4,562.28
Rate for Payer: Amerigroup Medicaid	$4,616.71
Rate for Payer: Amerigroup Medicare	$3,637.82
Rate for Payer: Cash Price	$6,403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,003.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,601.80
Rate for Payer: Iowa Total Care Managed Medicaid	$4,571.88
Rate for Payer: Medical Associates Commercial	$6,003.00
Rate for Payer: Medical Associates Managed Medicare	$3,601.80
Rate for Payer: Midlands Choice Commercial	$5,602.80
Rate for Payer: Molina Healthcare Managed Medicaid	$4,639.12
Rate for Payer: Partners Health Alliance Commercial	$4,142.07
Rate for Payer: United Healthcare Commercial	$7,203.60
Rate for Payer: United Healthcare Managed Medicare	$4,722.36

IMPLANT KNEE TIBAL BASEPLATE #8

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8026181
Hospital Revenue Code	278
Min. Negotiated Rate	$5,602.80
Max. Negotiated Rate	$7,203.60
Rate for Payer: Aetna of IA Commercial	$7,203.60
Rate for Payer: Aetna of IA Medical Rental Products	$7,203.60
Rate for Payer: Cash Price	$6,403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,003.00
Rate for Payer: Medical Associates Commercial	$6,003.00
Rate for Payer: Midlands Choice Commercial	$5,602.80
Rate for Payer: United Healthcare Commercial	$7,203.60

IMPLANT KNEE TIBIAL AUGMENT HALF BLOCK

Facility

$2,723.00

Service Code	HCPCS C1776
Hospital Charge Code	8026186
Hospital Revenue Code	278
Min. Negotiated Rate	$1,225.35
Max. Negotiated Rate	$2,450.70
Rate for Payer: Aetna of IA Commercial	$2,450.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,450.70
Rate for Payer: Aetna of IA Medicare	$1,552.11
Rate for Payer: Amerigroup Medicaid	$1,570.63
Rate for Payer: Amerigroup Medicare	$1,237.60
Rate for Payer: Cash Price	$2,178.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,042.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,225.35
Rate for Payer: Iowa Total Care Managed Medicaid	$1,555.38
Rate for Payer: Medical Associates Commercial	$2,042.25
Rate for Payer: Medical Associates Managed Medicare	$1,225.35
Rate for Payer: Midlands Choice Commercial	$1,906.10
Rate for Payer: Molina Healthcare Managed Medicaid	$1,578.25
Rate for Payer: Partners Health Alliance Commercial	$1,409.15
Rate for Payer: United Healthcare Commercial	$2,450.70
Rate for Payer: United Healthcare Managed Medicare	$1,606.57

IMPLANT KNEE TIBIAL AUGMENT HALF BLOCK

Facility

$2,723.00

Service Code	HCPCS C1776
Hospital Charge Code	8026186
Hospital Revenue Code	278
Min. Negotiated Rate	$1,906.10
Max. Negotiated Rate	$2,450.70
Rate for Payer: Aetna of IA Commercial	$2,450.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,450.70
Rate for Payer: Cash Price	$2,178.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,042.25
Rate for Payer: Medical Associates Commercial	$2,042.25
Rate for Payer: Midlands Choice Commercial	$1,906.10
Rate for Payer: United Healthcare Commercial	$2,450.70

IMPLANT KNEE TIBIAL BASEPLATE

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046842
Hospital Revenue Code	278
Min. Negotiated Rate	$3,601.80
Max. Negotiated Rate	$7,203.60
Rate for Payer: Aetna of IA Commercial	$7,203.60
Rate for Payer: Aetna of IA Medical Rental Products	$7,203.60
Rate for Payer: Aetna of IA Medicare	$4,562.28
Rate for Payer: Amerigroup Medicaid	$4,616.71
Rate for Payer: Amerigroup Medicare	$3,637.82
Rate for Payer: Cash Price	$6,403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,003.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,601.80
Rate for Payer: Iowa Total Care Managed Medicaid	$4,571.88
Rate for Payer: Medical Associates Commercial	$6,003.00
Rate for Payer: Medical Associates Managed Medicare	$3,601.80
Rate for Payer: Midlands Choice Commercial	$5,602.80
Rate for Payer: Molina Healthcare Managed Medicaid	$4,639.12
Rate for Payer: Partners Health Alliance Commercial	$4,142.07
Rate for Payer: United Healthcare Commercial	$7,203.60
Rate for Payer: United Healthcare Managed Medicare	$4,722.36

IMPLANT KNEE TIBIAL BASEPLATE

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046842
Hospital Revenue Code	278
Min. Negotiated Rate	$5,602.80
Max. Negotiated Rate	$7,203.60
Rate for Payer: Aetna of IA Commercial	$7,203.60
Rate for Payer: Aetna of IA Medical Rental Products	$7,203.60
Rate for Payer: Cash Price	$6,403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,003.00
Rate for Payer: Medical Associates Commercial	$6,003.00
Rate for Payer: Midlands Choice Commercial	$5,602.80
Rate for Payer: United Healthcare Commercial	$7,203.60

IMPLANT KNEE TIBIAL BASEPLATE #3

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046840
Hospital Revenue Code	278
Min. Negotiated Rate	$3,601.80
Max. Negotiated Rate	$7,203.60
Rate for Payer: Aetna of IA Commercial	$7,203.60
Rate for Payer: Aetna of IA Medical Rental Products	$7,203.60
Rate for Payer: Aetna of IA Medicare	$4,562.28
Rate for Payer: Amerigroup Medicaid	$4,616.71
Rate for Payer: Amerigroup Medicare	$3,637.82
Rate for Payer: Cash Price	$6,403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,003.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,601.80
Rate for Payer: Iowa Total Care Managed Medicaid	$4,571.88
Rate for Payer: Medical Associates Commercial	$6,003.00
Rate for Payer: Medical Associates Managed Medicare	$3,601.80
Rate for Payer: Midlands Choice Commercial	$5,602.80
Rate for Payer: Molina Healthcare Managed Medicaid	$4,639.12
Rate for Payer: Partners Health Alliance Commercial	$4,142.07
Rate for Payer: United Healthcare Commercial	$7,203.60
Rate for Payer: United Healthcare Managed Medicare	$4,722.36

IMPLANT KNEE TIBIAL BASEPLATE #3

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046840
Hospital Revenue Code	278
Min. Negotiated Rate	$5,602.80
Max. Negotiated Rate	$7,203.60
Rate for Payer: Aetna of IA Commercial	$7,203.60
Rate for Payer: Aetna of IA Medical Rental Products	$7,203.60
Rate for Payer: Cash Price	$6,403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,003.00
Rate for Payer: Medical Associates Commercial	$6,003.00
Rate for Payer: Midlands Choice Commercial	$5,602.80
Rate for Payer: United Healthcare Commercial	$7,203.60

IMPLANT KNEE TIBIAL BASEPLATE #4

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046841
Hospital Revenue Code	278
Min. Negotiated Rate	$5,602.80
Max. Negotiated Rate	$7,203.60
Rate for Payer: Aetna of IA Commercial	$7,203.60
Rate for Payer: Aetna of IA Medical Rental Products	$7,203.60
Rate for Payer: Cash Price	$6,403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,003.00
Rate for Payer: Medical Associates Commercial	$6,003.00
Rate for Payer: Midlands Choice Commercial	$5,602.80
Rate for Payer: United Healthcare Commercial	$7,203.60

Know your out-of-pocket cost for care.

All Charges