Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT LOCK SCREW KNEE 5X25 FULL TH

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8046335
Hospital Revenue Code	278
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of IA Commercial	$270.90
Rate for Payer: Aetna of IA Medical Rental Products	$270.90
Rate for Payer: Cash Price	$240.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.75
Rate for Payer: Medical Associates Commercial	$225.75
Rate for Payer: Midlands Choice Commercial	$210.70
Rate for Payer: United Healthcare Commercial	$270.90

IMPLANT LOCK SCREW KNEE 5X30 FULL TH

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8046337
Hospital Revenue Code	278
Min. Negotiated Rate	$135.45
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of IA Commercial	$270.90
Rate for Payer: Aetna of IA Medical Rental Products	$270.90
Rate for Payer: Aetna of IA Medicare	$171.57
Rate for Payer: Amerigroup Medicaid	$173.62
Rate for Payer: Amerigroup Medicare	$136.80
Rate for Payer: Cash Price	$240.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.45
Rate for Payer: Iowa Total Care Managed Medicaid	$171.93
Rate for Payer: Medical Associates Commercial	$225.75
Rate for Payer: Medical Associates Managed Medicare	$135.45
Rate for Payer: Midlands Choice Commercial	$210.70
Rate for Payer: Molina Healthcare Managed Medicaid	$174.46
Rate for Payer: Partners Health Alliance Commercial	$155.77
Rate for Payer: United Healthcare Commercial	$270.90
Rate for Payer: United Healthcare Managed Medicare	$177.59

IMPLANT LOCK SCREW KNEE 5X30 FULL TH

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8046337
Hospital Revenue Code	278
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of IA Commercial	$270.90
Rate for Payer: Aetna of IA Medical Rental Products	$270.90
Rate for Payer: Cash Price	$240.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.75
Rate for Payer: Medical Associates Commercial	$225.75
Rate for Payer: Midlands Choice Commercial	$210.70
Rate for Payer: United Healthcare Commercial	$270.90

IMPLANT LOCK SCREW KNEE 5X35 FULL TH

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8046339
Hospital Revenue Code	278
Min. Negotiated Rate	$135.45
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of IA Commercial	$270.90
Rate for Payer: Aetna of IA Medical Rental Products	$270.90
Rate for Payer: Aetna of IA Medicare	$171.57
Rate for Payer: Amerigroup Medicaid	$173.62
Rate for Payer: Amerigroup Medicare	$136.80
Rate for Payer: Cash Price	$240.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.45
Rate for Payer: Iowa Total Care Managed Medicaid	$171.93
Rate for Payer: Medical Associates Commercial	$225.75
Rate for Payer: Medical Associates Managed Medicare	$135.45
Rate for Payer: Midlands Choice Commercial	$210.70
Rate for Payer: Molina Healthcare Managed Medicaid	$174.46
Rate for Payer: Partners Health Alliance Commercial	$155.77
Rate for Payer: United Healthcare Commercial	$270.90
Rate for Payer: United Healthcare Managed Medicare	$177.59

IMPLANT LOCK SCREW KNEE 5X35 FULL TH

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8046339
Hospital Revenue Code	278
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of IA Commercial	$270.90
Rate for Payer: Aetna of IA Medical Rental Products	$270.90
Rate for Payer: Cash Price	$240.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.75
Rate for Payer: Medical Associates Commercial	$225.75
Rate for Payer: Midlands Choice Commercial	$210.70
Rate for Payer: United Healthcare Commercial	$270.90

IMPLANT LOCK SCREW KNEE 5X40 FULL TH

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8046341
Hospital Revenue Code	278
Min. Negotiated Rate	$135.45
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of IA Commercial	$270.90
Rate for Payer: Aetna of IA Medical Rental Products	$270.90
Rate for Payer: Aetna of IA Medicare	$171.57
Rate for Payer: Amerigroup Medicaid	$173.62
Rate for Payer: Amerigroup Medicare	$136.80
Rate for Payer: Cash Price	$240.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.45
Rate for Payer: Iowa Total Care Managed Medicaid	$171.93
Rate for Payer: Medical Associates Commercial	$225.75
Rate for Payer: Medical Associates Managed Medicare	$135.45
Rate for Payer: Midlands Choice Commercial	$210.70
Rate for Payer: Molina Healthcare Managed Medicaid	$174.46
Rate for Payer: Partners Health Alliance Commercial	$155.77
Rate for Payer: United Healthcare Commercial	$270.90
Rate for Payer: United Healthcare Managed Medicare	$177.59

IMPLANT LOCK SCREW KNEE 5X40 FULL TH

Facility

$301.00

Service Code	HCPCS C1713
Hospital Charge Code	8046341
Hospital Revenue Code	278
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of IA Commercial	$270.90
Rate for Payer: Aetna of IA Medical Rental Products	$270.90
Rate for Payer: Cash Price	$240.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.75
Rate for Payer: Medical Associates Commercial	$225.75
Rate for Payer: Midlands Choice Commercial	$210.70
Rate for Payer: United Healthcare Commercial	$270.90

IMPLANT LOCK SCREW T7 2.3X20MM

Facility

$201.00

Service Code	HCPCS C1713
Hospital Charge Code	8046807
Hospital Revenue Code	278
Min. Negotiated Rate	$90.45
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Aetna of IA Medicare	$114.57
Rate for Payer: Amerigroup Medicaid	$115.94
Rate for Payer: Amerigroup Medicare	$91.35
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.45
Rate for Payer: Iowa Total Care Managed Medicaid	$114.81
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Medical Associates Managed Medicare	$90.45
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Molina Healthcare Managed Medicaid	$116.50
Rate for Payer: Partners Health Alliance Commercial	$104.02
Rate for Payer: United Healthcare Commercial	$180.90
Rate for Payer: United Healthcare Managed Medicare	$118.59

IMPLANT LOCK SCREW T7 2.3X20MM

Facility

$201.00

Service Code	HCPCS C1713
Hospital Charge Code	8046807
Hospital Revenue Code	278
Min. Negotiated Rate	$140.70
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: United Healthcare Commercial	$180.90

IMPLANT LOCK SCREW T7 2.3X22MM

Facility

$201.00

Service Code	HCPCS C1713
Hospital Charge Code	8046808
Hospital Revenue Code	278
Min. Negotiated Rate	$90.45
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Aetna of IA Medicare	$114.57
Rate for Payer: Amerigroup Medicaid	$115.94
Rate for Payer: Amerigroup Medicare	$91.35
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.45
Rate for Payer: Iowa Total Care Managed Medicaid	$114.81
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Medical Associates Managed Medicare	$90.45
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Molina Healthcare Managed Medicaid	$116.50
Rate for Payer: Partners Health Alliance Commercial	$104.02
Rate for Payer: United Healthcare Commercial	$180.90
Rate for Payer: United Healthcare Managed Medicare	$118.59

IMPLANT LOCK SCREW T7 2.3X22MM

Facility

$201.00

Service Code	HCPCS C1713
Hospital Charge Code	8046808
Hospital Revenue Code	278
Min. Negotiated Rate	$140.70
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: United Healthcare Commercial	$180.90

IMPLANT MONOTUBE TRIAX WRIST KT

Facility

$3,987.00

Service Code	HCPCS C1713
Hospital Charge Code	8026166
Hospital Revenue Code	278
Min. Negotiated Rate	$1,794.15
Max. Negotiated Rate	$3,588.30
Rate for Payer: Aetna of IA Commercial	$3,588.30
Rate for Payer: Aetna of IA Medical Rental Products	$3,588.30
Rate for Payer: Aetna of IA Medicare	$2,272.59
Rate for Payer: Amerigroup Medicaid	$2,299.70
Rate for Payer: Amerigroup Medicare	$1,812.09
Rate for Payer: Cash Price	$3,189.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,990.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,794.15
Rate for Payer: Iowa Total Care Managed Medicaid	$2,277.37
Rate for Payer: Medical Associates Commercial	$2,990.25
Rate for Payer: Medical Associates Managed Medicare	$1,794.15
Rate for Payer: Midlands Choice Commercial	$2,790.90
Rate for Payer: Molina Healthcare Managed Medicaid	$2,310.87
Rate for Payer: Partners Health Alliance Commercial	$2,063.27
Rate for Payer: United Healthcare Commercial	$3,588.30
Rate for Payer: United Healthcare Managed Medicare	$2,352.33

IMPLANT MONOTUBE TRIAX WRIST KT

Facility

$3,987.00

Service Code	HCPCS C1713
Hospital Charge Code	8026166
Hospital Revenue Code	278
Min. Negotiated Rate	$2,790.90
Max. Negotiated Rate	$3,588.30
Rate for Payer: Aetna of IA Commercial	$3,588.30
Rate for Payer: Aetna of IA Medical Rental Products	$3,588.30
Rate for Payer: Cash Price	$3,189.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,990.25
Rate for Payer: Medical Associates Commercial	$2,990.25
Rate for Payer: Midlands Choice Commercial	$2,790.90
Rate for Payer: United Healthcare Commercial	$3,588.30

IMPLANT PIN KIT

Facility

$351.00

Service Code	HCPCS C1713
Hospital Charge Code	8047042
Hospital Revenue Code	278
Min. Negotiated Rate	$157.95
Max. Negotiated Rate	$315.90
Rate for Payer: Aetna of IA Commercial	$315.90
Rate for Payer: Aetna of IA Medical Rental Products	$315.90
Rate for Payer: Aetna of IA Medicare	$200.07
Rate for Payer: Amerigroup Medicaid	$202.46
Rate for Payer: Amerigroup Medicare	$159.53
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$263.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$157.95
Rate for Payer: Iowa Total Care Managed Medicaid	$200.49
Rate for Payer: Medical Associates Commercial	$263.25
Rate for Payer: Medical Associates Managed Medicare	$157.95
Rate for Payer: Midlands Choice Commercial	$245.70
Rate for Payer: Molina Healthcare Managed Medicaid	$203.44
Rate for Payer: Partners Health Alliance Commercial	$181.64
Rate for Payer: United Healthcare Commercial	$315.90
Rate for Payer: United Healthcare Managed Medicare	$207.09

IMPLANT PIN KIT

Facility

$351.00

Service Code	HCPCS C1713
Hospital Charge Code	8047042
Hospital Revenue Code	278
Min. Negotiated Rate	$245.70
Max. Negotiated Rate	$315.90
Rate for Payer: Aetna of IA Commercial	$315.90
Rate for Payer: Aetna of IA Medical Rental Products	$315.90
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$263.25
Rate for Payer: Medical Associates Commercial	$263.25
Rate for Payer: Midlands Choice Commercial	$245.70
Rate for Payer: United Healthcare Commercial	$315.90

IMPLANT PLATE LEFT SMALL

Facility

$1,919.00

Service Code	HCPCS C1713
Hospital Charge Code	8047040
Hospital Revenue Code	278
Min. Negotiated Rate	$863.55
Max. Negotiated Rate	$1,727.10
Rate for Payer: Aetna of IA Commercial	$1,727.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,727.10
Rate for Payer: Aetna of IA Medicare	$1,093.83
Rate for Payer: Amerigroup Medicaid	$1,106.88
Rate for Payer: Amerigroup Medicare	$872.19
Rate for Payer: Cash Price	$1,535.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,439.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$863.55
Rate for Payer: Iowa Total Care Managed Medicaid	$1,096.13
Rate for Payer: Medical Associates Commercial	$1,439.25
Rate for Payer: Medical Associates Managed Medicare	$863.55
Rate for Payer: Midlands Choice Commercial	$1,343.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1,112.25
Rate for Payer: Partners Health Alliance Commercial	$993.08
Rate for Payer: United Healthcare Commercial	$1,727.10
Rate for Payer: United Healthcare Managed Medicare	$1,132.21

IMPLANT PLATE LEFT SMALL

Facility

$1,919.00

Service Code	HCPCS C1713
Hospital Charge Code	8047040
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.30
Max. Negotiated Rate	$1,727.10
Rate for Payer: Aetna of IA Commercial	$1,727.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,727.10
Rate for Payer: Cash Price	$1,535.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,439.25
Rate for Payer: Medical Associates Commercial	$1,439.25
Rate for Payer: Midlands Choice Commercial	$1,343.30
Rate for Payer: United Healthcare Commercial	$1,727.10

IMPLANT PLATE RIGHT SMALL

Facility

$1,919.00

Service Code	HCPCS C1713
Hospital Charge Code	8047041
Hospital Revenue Code	278
Min. Negotiated Rate	$1,343.30
Max. Negotiated Rate	$1,727.10
Rate for Payer: Aetna of IA Commercial	$1,727.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,727.10
Rate for Payer: Cash Price	$1,535.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,439.25
Rate for Payer: Medical Associates Commercial	$1,439.25
Rate for Payer: Midlands Choice Commercial	$1,343.30
Rate for Payer: United Healthcare Commercial	$1,727.10

IMPLANT PLATE RIGHT SMALL

Facility

$1,919.00

Service Code	HCPCS C1713
Hospital Charge Code	8047041
Hospital Revenue Code	278
Min. Negotiated Rate	$863.55
Max. Negotiated Rate	$1,727.10
Rate for Payer: Aetna of IA Commercial	$1,727.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,727.10
Rate for Payer: Aetna of IA Medicare	$1,093.83
Rate for Payer: Amerigroup Medicaid	$1,106.88
Rate for Payer: Amerigroup Medicare	$872.19
Rate for Payer: Cash Price	$1,535.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,439.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$863.55
Rate for Payer: Iowa Total Care Managed Medicaid	$1,096.13
Rate for Payer: Medical Associates Commercial	$1,439.25
Rate for Payer: Medical Associates Managed Medicare	$863.55
Rate for Payer: Midlands Choice Commercial	$1,343.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1,112.25
Rate for Payer: Partners Health Alliance Commercial	$993.08
Rate for Payer: United Healthcare Commercial	$1,727.10
Rate for Payer: United Healthcare Managed Medicare	$1,132.21

IMPLANT PUSHLOCK 2.9 BIO

Facility

$684.00

Service Code	HCPCS C1713
Hospital Charge Code	8026410
Hospital Revenue Code	278
Min. Negotiated Rate	$307.80
Max. Negotiated Rate	$615.60
Rate for Payer: Aetna of IA Commercial	$615.60
Rate for Payer: Aetna of IA Medical Rental Products	$615.60
Rate for Payer: Aetna of IA Medicare	$389.88
Rate for Payer: Amerigroup Medicaid	$394.53
Rate for Payer: Amerigroup Medicare	$310.88
Rate for Payer: Cash Price	$547.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$513.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$307.80
Rate for Payer: Iowa Total Care Managed Medicaid	$390.70
Rate for Payer: Medical Associates Commercial	$513.00
Rate for Payer: Medical Associates Managed Medicare	$307.80
Rate for Payer: Midlands Choice Commercial	$478.80
Rate for Payer: Molina Healthcare Managed Medicaid	$396.45
Rate for Payer: Partners Health Alliance Commercial	$353.97
Rate for Payer: United Healthcare Commercial	$615.60
Rate for Payer: United Healthcare Managed Medicare	$403.56

IMPLANT PUSHLOCK 2.9 BIO

Facility

$684.00

Service Code	HCPCS C1713
Hospital Charge Code	8026410
Hospital Revenue Code	278
Min. Negotiated Rate	$478.80
Max. Negotiated Rate	$615.60
Rate for Payer: Aetna of IA Commercial	$615.60
Rate for Payer: Aetna of IA Medical Rental Products	$615.60
Rate for Payer: Cash Price	$547.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$513.00
Rate for Payer: Medical Associates Commercial	$513.00
Rate for Payer: Midlands Choice Commercial	$478.80
Rate for Payer: United Healthcare Commercial	$615.60

IMPLANT PUSHLOCK 4.5MM

Facility

$690.00

Service Code	HCPCS C1713
Hospital Charge Code	8026409
Hospital Revenue Code	278
Min. Negotiated Rate	$310.50
Max. Negotiated Rate	$621.00
Rate for Payer: Aetna of IA Commercial	$621.00
Rate for Payer: Aetna of IA Medical Rental Products	$621.00
Rate for Payer: Aetna of IA Medicare	$393.30
Rate for Payer: Amerigroup Medicaid	$397.99
Rate for Payer: Amerigroup Medicare	$313.60
Rate for Payer: Cash Price	$552.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$517.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$310.50
Rate for Payer: Iowa Total Care Managed Medicaid	$394.13
Rate for Payer: Medical Associates Commercial	$517.50
Rate for Payer: Medical Associates Managed Medicare	$310.50
Rate for Payer: Midlands Choice Commercial	$483.00
Rate for Payer: Molina Healthcare Managed Medicaid	$399.92
Rate for Payer: Partners Health Alliance Commercial	$357.08
Rate for Payer: United Healthcare Commercial	$621.00
Rate for Payer: United Healthcare Managed Medicare	$407.10

IMPLANT PUSHLOCK 4.5MM

Facility

$690.00

Service Code	HCPCS C1713
Hospital Charge Code	8026409
Hospital Revenue Code	278
Min. Negotiated Rate	$483.00
Max. Negotiated Rate	$621.00
Rate for Payer: Aetna of IA Commercial	$621.00
Rate for Payer: Aetna of IA Medical Rental Products	$621.00
Rate for Payer: Cash Price	$552.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$517.50
Rate for Payer: Medical Associates Commercial	$517.50
Rate for Payer: Midlands Choice Commercial	$483.00
Rate for Payer: United Healthcare Commercial	$621.00

IMPLANT SUTURETAK 2.4MM

Facility

$591.00

Service Code	HCPCS C1713
Hospital Charge Code	8026418
Hospital Revenue Code	278
Min. Negotiated Rate	$265.95
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of IA Commercial	$531.90
Rate for Payer: Aetna of IA Medical Rental Products	$531.90
Rate for Payer: Aetna of IA Medicare	$336.87
Rate for Payer: Amerigroup Medicaid	$340.89
Rate for Payer: Amerigroup Medicare	$268.61
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$443.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$265.95
Rate for Payer: Iowa Total Care Managed Medicaid	$337.58
Rate for Payer: Medical Associates Commercial	$443.25
Rate for Payer: Medical Associates Managed Medicare	$265.95
Rate for Payer: Midlands Choice Commercial	$413.70
Rate for Payer: Molina Healthcare Managed Medicaid	$342.54
Rate for Payer: Partners Health Alliance Commercial	$305.84
Rate for Payer: United Healthcare Commercial	$531.90
Rate for Payer: United Healthcare Managed Medicare	$348.69

IMPLANT SUTURETAK 2.4MM

Facility

$591.00

Service Code	HCPCS C1713
Hospital Charge Code	8026418
Hospital Revenue Code	278
Min. Negotiated Rate	$413.70
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of IA Commercial	$531.90
Rate for Payer: Aetna of IA Medical Rental Products	$531.90
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$443.25
Rate for Payer: Medical Associates Commercial	$443.25
Rate for Payer: Midlands Choice Commercial	$413.70
Rate for Payer: United Healthcare Commercial	$531.90

Know your out-of-pocket cost for care.

All Charges