Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT TITANIUM LAG SCREW 10.5X90MM

Facility

$619.00

Service Code	HCPCS C1713
Hospital Charge Code	8046415
Hospital Revenue Code	278
Min. Negotiated Rate	$278.55
Max. Negotiated Rate	$557.10
Rate for Payer: Aetna of IA Commercial	$557.10
Rate for Payer: Aetna of IA Medical Rental Products	$557.10
Rate for Payer: Aetna of IA Medicare	$352.83
Rate for Payer: Amerigroup Medicaid	$357.04
Rate for Payer: Amerigroup Medicare	$281.34
Rate for Payer: Cash Price	$495.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$464.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$278.55
Rate for Payer: Iowa Total Care Managed Medicaid	$353.57
Rate for Payer: Medical Associates Commercial	$464.25
Rate for Payer: Medical Associates Managed Medicare	$278.55
Rate for Payer: Midlands Choice Commercial	$433.30
Rate for Payer: Molina Healthcare Managed Medicaid	$358.77
Rate for Payer: Partners Health Alliance Commercial	$320.33
Rate for Payer: United Healthcare Commercial	$557.10
Rate for Payer: United Healthcare Managed Medicare	$365.21

IMPLANT TITANIUM LAG SCREW 10.5X90MM

Facility

$619.00

Service Code	HCPCS C1713
Hospital Charge Code	8046415
Hospital Revenue Code	278
Min. Negotiated Rate	$433.30
Max. Negotiated Rate	$557.10
Rate for Payer: Aetna of IA Commercial	$557.10
Rate for Payer: Aetna of IA Medical Rental Products	$557.10
Rate for Payer: Cash Price	$495.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$464.25
Rate for Payer: Medical Associates Commercial	$464.25
Rate for Payer: Midlands Choice Commercial	$433.30
Rate for Payer: United Healthcare Commercial	$557.10

IMPLANT TITANIUM LAG SCREW 10.5X95MM

Facility

$619.00

Service Code	HCPCS C1713
Hospital Charge Code	8046416
Hospital Revenue Code	278
Min. Negotiated Rate	$278.55
Max. Negotiated Rate	$557.10
Rate for Payer: Aetna of IA Commercial	$557.10
Rate for Payer: Aetna of IA Medical Rental Products	$557.10
Rate for Payer: Aetna of IA Medicare	$352.83
Rate for Payer: Amerigroup Medicaid	$357.04
Rate for Payer: Amerigroup Medicare	$281.34
Rate for Payer: Cash Price	$495.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$464.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$278.55
Rate for Payer: Iowa Total Care Managed Medicaid	$353.57
Rate for Payer: Medical Associates Commercial	$464.25
Rate for Payer: Medical Associates Managed Medicare	$278.55
Rate for Payer: Midlands Choice Commercial	$433.30
Rate for Payer: Molina Healthcare Managed Medicaid	$358.77
Rate for Payer: Partners Health Alliance Commercial	$320.33
Rate for Payer: United Healthcare Commercial	$557.10
Rate for Payer: United Healthcare Managed Medicare	$365.21

IMPLANT TITANIUM LAG SCREW 10.5X95MM

Facility

$619.00

Service Code	HCPCS C1713
Hospital Charge Code	8046416
Hospital Revenue Code	278
Min. Negotiated Rate	$433.30
Max. Negotiated Rate	$557.10
Rate for Payer: Aetna of IA Commercial	$557.10
Rate for Payer: Aetna of IA Medical Rental Products	$557.10
Rate for Payer: Cash Price	$495.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$464.25
Rate for Payer: Medical Associates Commercial	$464.25
Rate for Payer: Midlands Choice Commercial	$433.30
Rate for Payer: United Healthcare Commercial	$557.10

IMPLANT TITANIUM LOCK SCREW 5X25 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046334
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 LOCK SCREW 5X25 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046334
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 LOCK SCREW 5X30 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046336
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 LOCK SCREW 5X30 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046336
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 LOCK SCREW 5X35 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046338
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 LOCK SCREW 5X35 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046338
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 LOCK SCREW 5X40 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046340
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 LOCK SCREW 5X40 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046340
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 LOCK SCREW 5X45 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046342
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 LOCK SCREW 5X45 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046342
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 LOCK SCREW 5X50 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046343
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 LOCK SCREW 5X50 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046343
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 LOCK SCREW 5X55 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046344
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 LOCK SCREW 5X55 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046344
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 LOCK SCREW 5X60 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046345
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 LOCK SCREW 5X60 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046345
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 LOCK SCREW 5X65 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046346
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 LOCK SCREW 5X65 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046346
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 LOCK SCREW 5X70 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046347
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 LOCK SCREW 5X70 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046347
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 LOCK SCREW 5X75 FULL TH

Facility

$215.00

Service Code	HCPCS C1713
Hospital Charge Code	8046348
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

Know your out-of-pocket cost for care.

All Charges