Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

IMPLANT KNEE TIBIAL BASEPLATE #6

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046843
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 #6

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046843
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 PRIMARY #7

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046844
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 PRIMARY #7

Facility

$8,004.00

Service Code	HCPCS C1776
Hospital Charge Code	8046844
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 BEARING 7

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046793
Hospital Revenue Code	278
Min. Negotiated Rate	$2,201.40
Max. Negotiated Rate	$4,402.80
Rate for Payer: Aetna of IA Commercial	$4,402.80
Rate for Payer: Aetna of IA Medical Rental Products	$4,402.80
Rate for Payer: Aetna of IA Medicare	$2,788.44
Rate for Payer: Amerigroup Medicaid	$2,821.71
Rate for Payer: Amerigroup Medicare	$2,223.41
Rate for Payer: Cash Price	$3,913.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,669.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,201.40
Rate for Payer: Iowa Total Care Managed Medicaid	$2,794.31
Rate for Payer: Medical Associates Commercial	$3,669.00
Rate for Payer: Medical Associates Managed Medicare	$2,201.40
Rate for Payer: Midlands Choice Commercial	$3,424.40
Rate for Payer: Molina Healthcare Managed Medicaid	$2,835.40
Rate for Payer: Partners Health Alliance Commercial	$2,531.61
Rate for Payer: United Healthcare Commercial	$4,402.80
Rate for Payer: United Healthcare Managed Medicare	$2,886.28

IMPLANT KNEE TIBIAL BEARING 7

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046793
Hospital Revenue Code	278
Min. Negotiated Rate	$3,424.40
Max. Negotiated Rate	$4,402.80
Rate for Payer: Aetna of IA Commercial	$4,402.80
Rate for Payer: Aetna of IA Medical Rental Products	$4,402.80
Rate for Payer: Cash Price	$3,913.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,669.00
Rate for Payer: Medical Associates Commercial	$3,669.00
Rate for Payer: Midlands Choice Commercial	$3,424.40
Rate for Payer: United Healthcare Commercial	$4,402.80

IMPLANT KNEE TIBIAL BEARING INSERT

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046859
Hospital Revenue Code	278
Min. Negotiated Rate	$3,528.70
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: United Healthcare Commercial	$4,536.90

IMPLANT KNEE TIBIAL BEARING INSERT

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046859
Hospital Revenue Code	278
Min. Negotiated Rate	$2,268.45
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Aetna of IA Medicare	$2,873.37
Rate for Payer: Amerigroup Medicaid	$2,907.65
Rate for Payer: Amerigroup Medicare	$2,291.13
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,268.45
Rate for Payer: Iowa Total Care Managed Medicaid	$2,879.42
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Medical Associates Managed Medicare	$2,268.45
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,921.76
Rate for Payer: Partners Health Alliance Commercial	$2,608.72
Rate for Payer: United Healthcare Commercial	$4,536.90
Rate for Payer: United Healthcare Managed Medicare	$2,974.19

IMPLANT KNEE TIBIAL BEARING INSERT-309

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046846
Hospital Revenue Code	278
Min. Negotiated Rate	$3,528.70
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: United Healthcare Commercial	$4,536.90

IMPLANT KNEE TIBIAL BEARING INSERT-309

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046846
Hospital Revenue Code	278
Min. Negotiated Rate	$2,268.45
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Aetna of IA Medicare	$2,873.37
Rate for Payer: Amerigroup Medicaid	$2,907.65
Rate for Payer: Amerigroup Medicare	$2,291.13
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,268.45
Rate for Payer: Iowa Total Care Managed Medicaid	$2,879.42
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Medical Associates Managed Medicare	$2,268.45
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,921.76
Rate for Payer: Partners Health Alliance Commercial	$2,608.72
Rate for Payer: United Healthcare Commercial	$4,536.90
Rate for Payer: United Healthcare Managed Medicare	$2,974.19

IMPLANT KNEE TIBIAL BEARING INSERT #3X11

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046847
Hospital Revenue Code	278
Min. Negotiated Rate	$3,424.40
Max. Negotiated Rate	$4,402.80
Rate for Payer: Aetna of IA Commercial	$4,402.80
Rate for Payer: Aetna of IA Medical Rental Products	$4,402.80
Rate for Payer: Cash Price	$3,913.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,669.00
Rate for Payer: Medical Associates Commercial	$3,669.00
Rate for Payer: Midlands Choice Commercial	$3,424.40
Rate for Payer: United Healthcare Commercial	$4,402.80

IMPLANT KNEE TIBIAL BEARING INSERT #3X11

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046847
Hospital Revenue Code	278
Min. Negotiated Rate	$2,201.40
Max. Negotiated Rate	$4,402.80
Rate for Payer: Aetna of IA Commercial	$4,402.80
Rate for Payer: Aetna of IA Medical Rental Products	$4,402.80
Rate for Payer: Aetna of IA Medicare	$2,788.44
Rate for Payer: Amerigroup Medicaid	$2,821.71
Rate for Payer: Amerigroup Medicare	$2,223.41
Rate for Payer: Cash Price	$3,913.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,669.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,201.40
Rate for Payer: Iowa Total Care Managed Medicaid	$2,794.31
Rate for Payer: Medical Associates Commercial	$3,669.00
Rate for Payer: Medical Associates Managed Medicare	$2,201.40
Rate for Payer: Midlands Choice Commercial	$3,424.40
Rate for Payer: Molina Healthcare Managed Medicaid	$2,835.40
Rate for Payer: Partners Health Alliance Commercial	$2,531.61
Rate for Payer: United Healthcare Commercial	$4,402.80
Rate for Payer: United Healthcare Managed Medicare	$2,886.28

IMPLANT KNEE TIBIAL BEARING INSERT #3X13

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046848
Hospital Revenue Code	278
Min. Negotiated Rate	$3,424.40
Max. Negotiated Rate	$4,402.80
Rate for Payer: Aetna of IA Commercial	$4,402.80
Rate for Payer: Aetna of IA Medical Rental Products	$4,402.80
Rate for Payer: Cash Price	$3,913.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,669.00
Rate for Payer: Medical Associates Commercial	$3,669.00
Rate for Payer: Midlands Choice Commercial	$3,424.40
Rate for Payer: United Healthcare Commercial	$4,402.80

IMPLANT KNEE TIBIAL BEARING INSERT #3X13

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046848
Hospital Revenue Code	278
Min. Negotiated Rate	$2,201.40
Max. Negotiated Rate	$4,402.80
Rate for Payer: Aetna of IA Commercial	$4,402.80
Rate for Payer: Aetna of IA Medical Rental Products	$4,402.80
Rate for Payer: Aetna of IA Medicare	$2,788.44
Rate for Payer: Amerigroup Medicaid	$2,821.71
Rate for Payer: Amerigroup Medicare	$2,223.41
Rate for Payer: Cash Price	$3,913.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,669.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,201.40
Rate for Payer: Iowa Total Care Managed Medicaid	$2,794.31
Rate for Payer: Medical Associates Commercial	$3,669.00
Rate for Payer: Medical Associates Managed Medicare	$2,201.40
Rate for Payer: Midlands Choice Commercial	$3,424.40
Rate for Payer: Molina Healthcare Managed Medicaid	$2,835.40
Rate for Payer: Partners Health Alliance Commercial	$2,531.61
Rate for Payer: United Healthcare Commercial	$4,402.80
Rate for Payer: United Healthcare Managed Medicare	$2,886.28

IMPLANT KNEE TIBIAL BEARING INSERT-409

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046849
Hospital Revenue Code	278
Min. Negotiated Rate	$3,528.70
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: United Healthcare Commercial	$4,536.90

IMPLANT KNEE TIBIAL BEARING INSERT-409

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046849
Hospital Revenue Code	278
Min. Negotiated Rate	$2,268.45
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Aetna of IA Medicare	$2,873.37
Rate for Payer: Amerigroup Medicaid	$2,907.65
Rate for Payer: Amerigroup Medicare	$2,291.13
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,268.45
Rate for Payer: Iowa Total Care Managed Medicaid	$2,879.42
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Medical Associates Managed Medicare	$2,268.45
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,921.76
Rate for Payer: Partners Health Alliance Commercial	$2,608.72
Rate for Payer: United Healthcare Commercial	$4,536.90
Rate for Payer: United Healthcare Managed Medicare	$2,974.19

IMPLANT KNEE TIBIAL BEARING INSERT-409-1

Facility

$5,227.00

Service Code	HCPCS C1776
Hospital Charge Code	8046876
Hospital Revenue Code	278
Min. Negotiated Rate	$3,658.90
Max. Negotiated Rate	$4,704.30
Rate for Payer: Aetna of IA Commercial	$4,704.30
Rate for Payer: Aetna of IA Medical Rental Products	$4,704.30
Rate for Payer: Cash Price	$4,181.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,920.25
Rate for Payer: Medical Associates Commercial	$3,920.25
Rate for Payer: Midlands Choice Commercial	$3,658.90
Rate for Payer: United Healthcare Commercial	$4,704.30

IMPLANT KNEE TIBIAL BEARING INSERT-409-1

Facility

$5,227.00

Service Code	HCPCS C1776
Hospital Charge Code	8046876
Hospital Revenue Code	278
Min. Negotiated Rate	$2,352.15
Max. Negotiated Rate	$4,704.30
Rate for Payer: Aetna of IA Commercial	$4,704.30
Rate for Payer: Aetna of IA Medical Rental Products	$4,704.30
Rate for Payer: Aetna of IA Medicare	$2,979.39
Rate for Payer: Amerigroup Medicaid	$3,014.93
Rate for Payer: Amerigroup Medicare	$2,375.67
Rate for Payer: Cash Price	$4,181.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,920.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,352.15
Rate for Payer: Iowa Total Care Managed Medicaid	$2,985.66
Rate for Payer: Medical Associates Commercial	$3,920.25
Rate for Payer: Medical Associates Managed Medicare	$2,352.15
Rate for Payer: Midlands Choice Commercial	$3,658.90
Rate for Payer: Molina Healthcare Managed Medicaid	$3,029.57
Rate for Payer: Partners Health Alliance Commercial	$2,704.97
Rate for Payer: United Healthcare Commercial	$4,704.30
Rate for Payer: United Healthcare Managed Medicare	$3,083.93

IMPLANT KNEE TIBIAL BEARING INSERT-416

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046877
Hospital Revenue Code	278
Min. Negotiated Rate	$3,424.40
Max. Negotiated Rate	$4,402.80
Rate for Payer: Aetna of IA Commercial	$4,402.80
Rate for Payer: Aetna of IA Medical Rental Products	$4,402.80
Rate for Payer: Cash Price	$3,913.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,669.00
Rate for Payer: Medical Associates Commercial	$3,669.00
Rate for Payer: Midlands Choice Commercial	$3,424.40
Rate for Payer: United Healthcare Commercial	$4,402.80

IMPLANT KNEE TIBIAL BEARING INSERT-416

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046877
Hospital Revenue Code	278
Min. Negotiated Rate	$2,201.40
Max. Negotiated Rate	$4,402.80
Rate for Payer: Aetna of IA Commercial	$4,402.80
Rate for Payer: Aetna of IA Medical Rental Products	$4,402.80
Rate for Payer: Aetna of IA Medicare	$2,788.44
Rate for Payer: Amerigroup Medicaid	$2,821.71
Rate for Payer: Amerigroup Medicare	$2,223.41
Rate for Payer: Cash Price	$3,913.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,669.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,201.40
Rate for Payer: Iowa Total Care Managed Medicaid	$2,794.31
Rate for Payer: Medical Associates Commercial	$3,669.00
Rate for Payer: Medical Associates Managed Medicare	$2,201.40
Rate for Payer: Midlands Choice Commercial	$3,424.40
Rate for Payer: Molina Healthcare Managed Medicaid	$2,835.40
Rate for Payer: Partners Health Alliance Commercial	$2,531.61
Rate for Payer: United Healthcare Commercial	$4,402.80
Rate for Payer: United Healthcare Managed Medicare	$2,886.28

IMPLANT KNEE TIBIAL BEARING INSERT #5

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046853
Hospital Revenue Code	278
Min. Negotiated Rate	$2,268.45
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Aetna of IA Medicare	$2,873.37
Rate for Payer: Amerigroup Medicaid	$2,907.65
Rate for Payer: Amerigroup Medicare	$2,291.13
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,268.45
Rate for Payer: Iowa Total Care Managed Medicaid	$2,879.42
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Medical Associates Managed Medicare	$2,268.45
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,921.76
Rate for Payer: Partners Health Alliance Commercial	$2,608.72
Rate for Payer: United Healthcare Commercial	$4,536.90
Rate for Payer: United Healthcare Managed Medicare	$2,974.19

IMPLANT KNEE TIBIAL BEARING INSERT #5

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046853
Hospital Revenue Code	278
Min. Negotiated Rate	$3,528.70
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: United Healthcare Commercial	$4,536.90

IMPLANT KNEE TIBIAL BEARING INSERT-509

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046852
Hospital Revenue Code	278
Min. Negotiated Rate	$2,268.45
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Aetna of IA Medicare	$2,873.37
Rate for Payer: Amerigroup Medicaid	$2,907.65
Rate for Payer: Amerigroup Medicare	$2,291.13
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,268.45
Rate for Payer: Iowa Total Care Managed Medicaid	$2,879.42
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Medical Associates Managed Medicare	$2,268.45
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,921.76
Rate for Payer: Partners Health Alliance Commercial	$2,608.72
Rate for Payer: United Healthcare Commercial	$4,536.90
Rate for Payer: United Healthcare Managed Medicare	$2,974.19

IMPLANT KNEE TIBIAL BEARING INSERT-509

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046852
Hospital Revenue Code	278
Min. Negotiated Rate	$3,528.70
Max. Negotiated Rate	$4,536.90
Rate for Payer: Aetna of IA Commercial	$4,536.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,536.90
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,780.75
Rate for Payer: Medical Associates Commercial	$3,780.75
Rate for Payer: Midlands Choice Commercial	$3,528.70
Rate for Payer: United Healthcare Commercial	$4,536.90

Know your out-of-pocket cost for care.

All Charges