Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT SUTURETAK 2 FIBERWIRES

Facility

$2,953.00

Service Code	HCPCS C1713
Hospital Charge Code	8047064
Hospital Revenue Code	278
Min. Negotiated Rate	$1,328.85
Max. Negotiated Rate	$2,657.70
Rate for Payer: Aetna of IA Commercial	$2,657.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,657.70
Rate for Payer: Aetna of IA Medicare	$1,683.21
Rate for Payer: Amerigroup Medicaid	$1,703.29
Rate for Payer: Amerigroup Medicare	$1,342.14
Rate for Payer: Cash Price	$2,362.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,214.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,328.85
Rate for Payer: Iowa Total Care Managed Medicaid	$1,686.75
Rate for Payer: Medical Associates Commercial	$2,214.75
Rate for Payer: Medical Associates Managed Medicare	$1,328.85
Rate for Payer: Midlands Choice Commercial	$2,067.10
Rate for Payer: Molina Healthcare Managed Medicaid	$1,711.56
Rate for Payer: Partners Health Alliance Commercial	$1,528.18
Rate for Payer: United Healthcare Commercial	$2,657.70
Rate for Payer: United Healthcare Managed Medicare	$1,742.27

IMPLANT SUTURETAK 2 FIBERWIRES

Facility

$2,953.00

Service Code	HCPCS C1713
Hospital Charge Code	8047064
Hospital Revenue Code	278
Min. Negotiated Rate	$2,067.10
Max. Negotiated Rate	$2,657.70
Rate for Payer: Aetna of IA Commercial	$2,657.70
Rate for Payer: Aetna of IA Medical Rental Products	$2,657.70
Rate for Payer: Cash Price	$2,362.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,214.75
Rate for Payer: Medical Associates Commercial	$2,214.75
Rate for Payer: Midlands Choice Commercial	$2,067.10
Rate for Payer: United Healthcare Commercial	$2,657.70

IMPLANT SUTURETAK 3.0MM

Facility

$555.00

Service Code	HCPCS C1713
Hospital Charge Code	8026417
Hospital Revenue Code	278
Min. Negotiated Rate	$249.75
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of IA Commercial	$499.50
Rate for Payer: Aetna of IA Medical Rental Products	$499.50
Rate for Payer: Aetna of IA Medicare	$316.35
Rate for Payer: Amerigroup Medicaid	$320.12
Rate for Payer: Amerigroup Medicare	$252.25
Rate for Payer: Cash Price	$444.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$416.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$249.75
Rate for Payer: Iowa Total Care Managed Medicaid	$317.02
Rate for Payer: Medical Associates Commercial	$416.25
Rate for Payer: Medical Associates Managed Medicare	$249.75
Rate for Payer: Midlands Choice Commercial	$388.50
Rate for Payer: Molina Healthcare Managed Medicaid	$321.68
Rate for Payer: Partners Health Alliance Commercial	$287.21
Rate for Payer: United Healthcare Commercial	$499.50
Rate for Payer: United Healthcare Managed Medicare	$327.45

IMPLANT SUTURETAK 3.0MM

Facility

$555.00

Service Code	HCPCS C1713
Hospital Charge Code	8026417
Hospital Revenue Code	278
Min. Negotiated Rate	$388.50
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of IA Commercial	$499.50
Rate for Payer: Aetna of IA Medical Rental Products	$499.50
Rate for Payer: Cash Price	$444.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$416.25
Rate for Payer: Medical Associates Commercial	$416.25
Rate for Payer: Midlands Choice Commercial	$388.50
Rate for Payer: United Healthcare Commercial	$499.50

IMPLANT SWIVELOCK (5 PER BOX)

Facility

$720.00

Service Code	HCPCS C1713
Hospital Charge Code	8026421
Hospital Revenue Code	278
Min. Negotiated Rate	$324.00
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of IA Commercial	$648.00
Rate for Payer: Aetna of IA Medical Rental Products	$648.00
Rate for Payer: Aetna of IA Medicare	$410.40
Rate for Payer: Amerigroup Medicaid	$415.30
Rate for Payer: Amerigroup Medicare	$327.24
Rate for Payer: Cash Price	$576.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$540.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$324.00
Rate for Payer: Iowa Total Care Managed Medicaid	$411.26
Rate for Payer: Medical Associates Commercial	$540.00
Rate for Payer: Medical Associates Managed Medicare	$324.00
Rate for Payer: Midlands Choice Commercial	$504.00
Rate for Payer: Molina Healthcare Managed Medicaid	$417.31
Rate for Payer: Partners Health Alliance Commercial	$372.60
Rate for Payer: United Healthcare Commercial	$648.00
Rate for Payer: United Healthcare Managed Medicare	$424.80

IMPLANT SWIVELOCK (5 PER BOX)

Facility

$720.00

Service Code	HCPCS C1713
Hospital Charge Code	8026421
Hospital Revenue Code	278
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of IA Commercial	$648.00
Rate for Payer: Aetna of IA Medical Rental Products	$648.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$540.00
Rate for Payer: Medical Associates Commercial	$540.00
Rate for Payer: Midlands Choice Commercial	$504.00
Rate for Payer: United Healthcare Commercial	$648.00

IMPLANT SYSTEM, CPR MINI SCORPION DX

Facility

$2,817.00

Service Code	HCPCS C1776
Hospital Charge Code	8757482
Hospital Revenue Code	278
Min. Negotiated Rate	$1,267.65
Max. Negotiated Rate	$2,535.30
Rate for Payer: Aetna of IA Commercial	$2,535.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,535.30
Rate for Payer: Aetna of IA Medicare	$1,605.69
Rate for Payer: Amerigroup Medicaid	$1,624.85
Rate for Payer: Amerigroup Medicare	$1,280.33
Rate for Payer: Cash Price	$2,253.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,112.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,267.65
Rate for Payer: Iowa Total Care Managed Medicaid	$1,609.07
Rate for Payer: Medical Associates Commercial	$2,112.75
Rate for Payer: Medical Associates Managed Medicare	$1,267.65
Rate for Payer: Midlands Choice Commercial	$1,971.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,632.73
Rate for Payer: Partners Health Alliance Commercial	$1,457.80
Rate for Payer: United Healthcare Commercial	$2,535.30
Rate for Payer: United Healthcare Managed Medicare	$1,662.03

IMPLANT SYSTEM, CPR MINI SCORPION DX

Facility

$2,817.00

Service Code	HCPCS C1776
Hospital Charge Code	8757482
Hospital Revenue Code	278
Min. Negotiated Rate	$1,971.90
Max. Negotiated Rate	$2,535.30
Rate for Payer: Aetna of IA Commercial	$2,535.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,535.30
Rate for Payer: Cash Price	$2,253.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,112.75
Rate for Payer: Medical Associates Commercial	$2,112.75
Rate for Payer: Midlands Choice Commercial	$1,971.90
Rate for Payer: United Healthcare Commercial	$2,535.30

IMPLANT SYSTEM, MPFL BIOCOMPOSITE

Facility

$2,677.00

Service Code	HCPCS C1776
Hospital Charge Code	8047047
Hospital Revenue Code	278
Min. Negotiated Rate	$1,873.90
Max. Negotiated Rate	$2,409.30
Rate for Payer: Aetna of IA Commercial	$2,409.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,409.30
Rate for Payer: Cash Price	$2,141.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,007.75
Rate for Payer: Medical Associates Commercial	$2,007.75
Rate for Payer: Midlands Choice Commercial	$1,873.90
Rate for Payer: United Healthcare Commercial	$2,409.30

IMPLANT SYSTEM, MPFL BIOCOMPOSITE

Facility

$2,677.00

Service Code	HCPCS C1776
Hospital Charge Code	8047047
Hospital Revenue Code	278
Min. Negotiated Rate	$1,204.65
Max. Negotiated Rate	$2,409.30
Rate for Payer: Aetna of IA Commercial	$2,409.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,409.30
Rate for Payer: Aetna of IA Medicare	$1,525.89
Rate for Payer: Amerigroup Medicaid	$1,544.09
Rate for Payer: Amerigroup Medicare	$1,216.70
Rate for Payer: Cash Price	$2,141.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,007.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,204.65
Rate for Payer: Iowa Total Care Managed Medicaid	$1,529.10
Rate for Payer: Medical Associates Commercial	$2,007.75
Rate for Payer: Medical Associates Managed Medicare	$1,204.65
Rate for Payer: Midlands Choice Commercial	$1,873.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,551.59
Rate for Payer: Partners Health Alliance Commercial	$1,385.35
Rate for Payer: United Healthcare Commercial	$2,409.30
Rate for Payer: United Healthcare Managed Medicare	$1,579.43

IMPLANT TIBIAL BEARING INSERT #4

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046851
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 TIBIAL BEARING INSERT #4

Facility

$4,892.00

Service Code	HCPCS C1776
Hospital Charge Code	8046851
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 TIBIAL BEARING INSERT CR 4X11MM

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046850
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 TIBIAL BEARING INSERT CR 4X11MM

Facility

$5,041.00

Service Code	HCPCS C1776
Hospital Charge Code	8046850
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 TIBIAL NAIL STANDARD 11X315MM

Facility

$3,449.00

Service Code	HCPCS C1713
Hospital Charge Code	8046333
Hospital Revenue Code	278
Min. Negotiated Rate	$1,552.05
Max. Negotiated Rate	$3,104.10
Rate for Payer: Aetna of IA Commercial	$3,104.10
Rate for Payer: Aetna of IA Medical Rental Products	$3,104.10
Rate for Payer: Aetna of IA Medicare	$1,965.93
Rate for Payer: Amerigroup Medicaid	$1,989.38
Rate for Payer: Amerigroup Medicare	$1,567.57
Rate for Payer: Cash Price	$2,759.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,586.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,552.05
Rate for Payer: Iowa Total Care Managed Medicaid	$1,970.07
Rate for Payer: Medical Associates Commercial	$2,586.75
Rate for Payer: Medical Associates Managed Medicare	$1,552.05
Rate for Payer: Midlands Choice Commercial	$2,414.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1,999.04
Rate for Payer: Partners Health Alliance Commercial	$1,784.86
Rate for Payer: United Healthcare Commercial	$3,104.10
Rate for Payer: United Healthcare Managed Medicare	$2,034.91

IMPLANT TIBIAL NAIL STANDARD 11X315MM

Facility

$3,449.00

Service Code	HCPCS C1713
Hospital Charge Code	8046333
Hospital Revenue Code	278
Min. Negotiated Rate	$2,414.30
Max. Negotiated Rate	$3,104.10
Rate for Payer: Aetna of IA Commercial	$3,104.10
Rate for Payer: Aetna of IA Medical Rental Products	$3,104.10
Rate for Payer: Cash Price	$2,759.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,586.75
Rate for Payer: Medical Associates Commercial	$2,586.75
Rate for Payer: Midlands Choice Commercial	$2,414.30
Rate for Payer: United Healthcare Commercial	$3,104.10

IMPLANT TIBIAL SIZE #5

Facility

$4,140.00

Service Code	HCPCS C1776
Hospital Charge Code	8046863
Hospital Revenue Code	278
Min. Negotiated Rate	$1,863.00
Max. Negotiated Rate	$3,726.00
Rate for Payer: Aetna of IA Commercial	$3,726.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,726.00
Rate for Payer: Aetna of IA Medicare	$2,359.80
Rate for Payer: Amerigroup Medicaid	$2,387.95
Rate for Payer: Amerigroup Medicare	$1,881.63
Rate for Payer: Cash Price	$3,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,105.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,863.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2,364.77
Rate for Payer: Medical Associates Commercial	$3,105.00
Rate for Payer: Medical Associates Managed Medicare	$1,863.00
Rate for Payer: Midlands Choice Commercial	$2,898.00
Rate for Payer: Molina Healthcare Managed Medicaid	$2,399.54
Rate for Payer: Partners Health Alliance Commercial	$2,142.45
Rate for Payer: United Healthcare Commercial	$3,726.00
Rate for Payer: United Healthcare Managed Medicare	$2,442.60

IMPLANT TIBIAL SIZE #5

Facility

$4,140.00

Service Code	HCPCS C1776
Hospital Charge Code	8046863
Hospital Revenue Code	278
Min. Negotiated Rate	$2,898.00
Max. Negotiated Rate	$3,726.00
Rate for Payer: Aetna of IA Commercial	$3,726.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,726.00
Rate for Payer: Cash Price	$3,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,105.00
Rate for Payer: Medical Associates Commercial	$3,105.00
Rate for Payer: Midlands Choice Commercial	$2,898.00
Rate for Payer: United Healthcare Commercial	$3,726.00

IMPLANT TIBIAL SIZE #6

Facility

$4,140.00

Service Code	HCPCS C1776
Hospital Charge Code	8046845
Hospital Revenue Code	278
Min. Negotiated Rate	$1,863.00
Max. Negotiated Rate	$3,726.00
Rate for Payer: Aetna of IA Commercial	$3,726.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,726.00
Rate for Payer: Aetna of IA Medicare	$2,359.80
Rate for Payer: Amerigroup Medicaid	$2,387.95
Rate for Payer: Amerigroup Medicare	$1,881.63
Rate for Payer: Cash Price	$3,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,105.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,863.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2,364.77
Rate for Payer: Medical Associates Commercial	$3,105.00
Rate for Payer: Medical Associates Managed Medicare	$1,863.00
Rate for Payer: Midlands Choice Commercial	$2,898.00
Rate for Payer: Molina Healthcare Managed Medicaid	$2,399.54
Rate for Payer: Partners Health Alliance Commercial	$2,142.45
Rate for Payer: United Healthcare Commercial	$3,726.00
Rate for Payer: United Healthcare Managed Medicare	$2,442.60

IMPLANT TIBIAL SIZE #6

Facility

$4,140.00

Service Code	HCPCS C1776
Hospital Charge Code	8046845
Hospital Revenue Code	278
Min. Negotiated Rate	$2,898.00
Max. Negotiated Rate	$3,726.00
Rate for Payer: Aetna of IA Commercial	$3,726.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,726.00
Rate for Payer: Cash Price	$3,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,105.00
Rate for Payer: Medical Associates Commercial	$3,105.00
Rate for Payer: Midlands Choice Commercial	$2,898.00
Rate for Payer: United Healthcare Commercial	$3,726.00

IMPLANT TIGERSTICK

Facility

$69.00

Service Code	HCPCS C1713
Hospital Charge Code	8026441
Hospital Revenue Code	278
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of IA Commercial	$62.10
Rate for Payer: Aetna of IA Medical Rental Products	$62.10
Rate for Payer: Cash Price	$55.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$51.75
Rate for Payer: Medical Associates Commercial	$51.75
Rate for Payer: Midlands Choice Commercial	$48.30
Rate for Payer: United Healthcare Commercial	$62.10

IMPLANT TIGERSTICK

Facility

$69.00

Service Code	HCPCS C1713
Hospital Charge Code	8026441
Hospital Revenue Code	278
Min. Negotiated Rate	$31.05
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of IA Commercial	$62.10
Rate for Payer: Aetna of IA Medical Rental Products	$62.10
Rate for Payer: Aetna of IA Medicare	$39.33
Rate for Payer: Amerigroup Medicaid	$39.80
Rate for Payer: Amerigroup Medicare	$31.36
Rate for Payer: Cash Price	$55.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$51.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.05
Rate for Payer: Iowa Total Care Managed Medicaid	$39.41
Rate for Payer: Medical Associates Commercial	$51.75
Rate for Payer: Medical Associates Managed Medicare	$31.05
Rate for Payer: Midlands Choice Commercial	$48.30
Rate for Payer: Molina Healthcare Managed Medicaid	$39.99
Rate for Payer: Partners Health Alliance Commercial	$35.71
Rate for Payer: United Healthcare Commercial	$62.10
Rate for Payer: United Healthcare Managed Medicare	$40.71

IMPLANT TITANIUM +10 END CAP

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046408
Hospital Revenue Code	278
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of IA Commercial	$193.50
Rate for Payer: Aetna of IA Medical Rental Products	$193.50
Rate for Payer: Aetna of IA Medicare	$122.55
Rate for Payer: Amerigroup Medicaid	$124.01
Rate for Payer: Amerigroup Medicare	$97.72
Rate for Payer: Cash Price	$172.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$161.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$96.75
Rate for Payer: Iowa Total Care Managed Medicaid	$122.81
Rate for Payer: Medical Associates Commercial	$161.25
Rate for Payer: Medical Associates Managed Medicare	$96.75
Rate for Payer: Midlands Choice Commercial	$150.50
Rate for Payer: Molina Healthcare Managed Medicaid	$124.61
Rate for Payer: Partners Health Alliance Commercial	$111.26
Rate for Payer: United Healthcare Commercial	$193.50
Rate for Payer: United Healthcare Managed Medicare	$126.85

IMPLANT TITANIUM +10 END CAP

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046408
Hospital Revenue Code	278
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of IA Commercial	$193.50
Rate for Payer: Aetna of IA Medical Rental Products	$193.50
Rate for Payer: Cash Price	$172.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$161.25
Rate for Payer: Medical Associates Commercial	$161.25
Rate for Payer: Midlands Choice Commercial	$150.50
Rate for Payer: United Healthcare Commercial	$193.50

IMPLANT TITANIUM +5 END CAP

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046407
Hospital Revenue Code	278
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of IA Commercial	$193.50
Rate for Payer: Aetna of IA Medical Rental Products	$193.50
Rate for Payer: Cash Price	$172.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$161.25
Rate for Payer: Medical Associates Commercial	$161.25
Rate for Payer: Midlands Choice Commercial	$150.50
Rate for Payer: United Healthcare Commercial	$193.50

Know your out-of-pocket cost for care.

All Charges