Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

LOCKING COMPR BROAD 13 HOLE / L 245MM

Facility

$279.00

Service Code	CPT C1713
Hospital Charge Code	8046761
Hospital Revenue Code	278
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

LOCKING COMPR BROAD 13 HOLE / L 245MM

Facility

$279.00

Service Code	CPT C1713
Hospital Charge Code	8046761
Hospital Revenue Code	278
Min. Negotiated Rate	$139.44
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$140.81
Rate for Payer: Amerigroup Medicare	$140.90
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$139.50
Rate for Payer: Iowa Total Care Managed Medicaid	$139.44
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$139.50
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$141.59
Rate for Payer: Molina Healthcare Managed Medicare	$141.51
Rate for Payer: Oscar Health of IA Commercial	$209.25
Rate for Payer: Partners Health Alliance Commercial	$209.25
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61

LOCKING COMPR BROAD 14 HOLE / L 263MM

Facility

$279.00

Service Code	CPT C1713
Hospital Charge Code	8046762
Hospital Revenue Code	278
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

LOCKING COMPR BROAD 14 HOLE / L 263MM

Facility

$279.00

Service Code	CPT C1713
Hospital Charge Code	8046762
Hospital Revenue Code	278
Min. Negotiated Rate	$139.44
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$140.81
Rate for Payer: Amerigroup Medicare	$140.90
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$139.50
Rate for Payer: Iowa Total Care Managed Medicaid	$139.44
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$139.50
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$141.59
Rate for Payer: Molina Healthcare Managed Medicare	$141.51
Rate for Payer: Oscar Health of IA Commercial	$209.25
Rate for Payer: Partners Health Alliance Commercial	$209.25
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61

LOCKING COMPR BROAD 6 HOLE / L 119MM

Facility

$224.00

Service Code	CPT C1713
Hospital Charge Code	8046754
Hospital Revenue Code	278
Min. Negotiated Rate	$111.96
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of IA Commercial	$201.60
Rate for Payer: Aetna of IA Medical Rental Products	$201.60
Rate for Payer: Aetna of IA Medicare	$127.68
Rate for Payer: Amerigroup Medicaid	$113.05
Rate for Payer: Amerigroup Medicare	$113.12
Rate for Payer: Cash Price	$179.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$168.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$112.00
Rate for Payer: Iowa Total Care Managed Medicaid	$111.96
Rate for Payer: Medical Associates Commercial	$168.00
Rate for Payer: Medical Associates Managed Medicare	$112.00
Rate for Payer: Midlands Choice Commercial	$156.80
Rate for Payer: Molina Healthcare Managed Medicaid	$113.68
Rate for Payer: Molina Healthcare Managed Medicare	$113.61
Rate for Payer: Oscar Health of IA Commercial	$168.00
Rate for Payer: Partners Health Alliance Commercial	$168.00
Rate for Payer: United Healthcare Commercial	$201.60
Rate for Payer: United Healthcare Managed Medicare	$132.16

LOCKING COMPR BROAD 6 HOLE / L 119MM

Facility

$224.00

Service Code	CPT C1713
Hospital Charge Code	8046754
Hospital Revenue Code	278
Min. Negotiated Rate	$156.80
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of IA Commercial	$201.60
Rate for Payer: Aetna of IA Medical Rental Products	$201.60
Rate for Payer: Cash Price	$179.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$168.00
Rate for Payer: Medical Associates Commercial	$168.00
Rate for Payer: Midlands Choice Commercial	$156.80
Rate for Payer: United Healthcare Commercial	$201.60

LOCKING COMPR BROAD 7 HOLE / L 137MM

Facility

$250.00

Service Code	CPT C1713
Hospital Charge Code	8046755
Hospital Revenue Code	278
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of IA Commercial	$225.00
Rate for Payer: Aetna of IA Medical Rental Products	$225.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$187.50
Rate for Payer: Medical Associates Commercial	$187.50
Rate for Payer: Midlands Choice Commercial	$175.00
Rate for Payer: United Healthcare Commercial	$225.00

LOCKING COMPR BROAD 7 HOLE / L 137MM

Facility

$250.00

Service Code	CPT C1713
Hospital Charge Code	8046755
Hospital Revenue Code	278
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of IA Commercial	$225.00
Rate for Payer: Aetna of IA Medical Rental Products	$225.00
Rate for Payer: Aetna of IA Medicare	$142.50
Rate for Payer: Amerigroup Medicaid	$126.18
Rate for Payer: Amerigroup Medicare	$126.25
Rate for Payer: Cash Price	$200.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$187.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.00
Rate for Payer: Iowa Total Care Managed Medicaid	$124.95
Rate for Payer: Medical Associates Commercial	$187.50
Rate for Payer: Medical Associates Managed Medicare	$125.00
Rate for Payer: Midlands Choice Commercial	$175.00
Rate for Payer: Molina Healthcare Managed Medicaid	$126.88
Rate for Payer: Molina Healthcare Managed Medicare	$126.80
Rate for Payer: Oscar Health of IA Commercial	$187.50
Rate for Payer: Partners Health Alliance Commercial	$187.50
Rate for Payer: United Healthcare Commercial	$225.00
Rate for Payer: United Healthcare Managed Medicare	$147.50

LOCKING COMPR BROAD 8 HOLE / L 155MM

Facility

$251.00

Service Code	CPT C1713
Hospital Charge Code	8046756
Hospital Revenue Code	278
Min. Negotiated Rate	$125.45
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna of IA Commercial	$225.90
Rate for Payer: Aetna of IA Medical Rental Products	$225.90
Rate for Payer: Aetna of IA Medicare	$143.07
Rate for Payer: Amerigroup Medicaid	$126.68
Rate for Payer: Amerigroup Medicare	$126.76
Rate for Payer: Cash Price	$200.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.50
Rate for Payer: Iowa Total Care Managed Medicaid	$125.45
Rate for Payer: Medical Associates Commercial	$188.25
Rate for Payer: Medical Associates Managed Medicare	$125.50
Rate for Payer: Midlands Choice Commercial	$175.70
Rate for Payer: Molina Healthcare Managed Medicaid	$127.38
Rate for Payer: Molina Healthcare Managed Medicare	$127.31
Rate for Payer: Oscar Health of IA Commercial	$188.25
Rate for Payer: Partners Health Alliance Commercial	$188.25
Rate for Payer: United Healthcare Commercial	$225.90
Rate for Payer: United Healthcare Managed Medicare	$148.09

LOCKING COMPR BROAD 8 HOLE / L 155MM

Facility

$251.00

Service Code	CPT C1713
Hospital Charge Code	8046756
Hospital Revenue Code	278
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna of IA Commercial	$225.90
Rate for Payer: Aetna of IA Medical Rental Products	$225.90
Rate for Payer: Cash Price	$200.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.25
Rate for Payer: Medical Associates Commercial	$188.25
Rate for Payer: Midlands Choice Commercial	$175.70
Rate for Payer: United Healthcare Commercial	$225.90

LOCKING COMPR BROAD 9 HOLE / L 173MM

Facility

$251.00

Service Code	CPT C1713
Hospital Charge Code	8046757
Hospital Revenue Code	278
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna of IA Commercial	$225.90
Rate for Payer: Aetna of IA Medical Rental Products	$225.90
Rate for Payer: Cash Price	$200.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.25
Rate for Payer: Medical Associates Commercial	$188.25
Rate for Payer: Midlands Choice Commercial	$175.70
Rate for Payer: United Healthcare Commercial	$225.90

LOCKING COMPR BROAD 9 HOLE / L 173MM

Facility

$251.00

Service Code	CPT C1713
Hospital Charge Code	8046757
Hospital Revenue Code	278
Min. Negotiated Rate	$125.45
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna of IA Commercial	$225.90
Rate for Payer: Aetna of IA Medical Rental Products	$225.90
Rate for Payer: Aetna of IA Medicare	$143.07
Rate for Payer: Amerigroup Medicaid	$126.68
Rate for Payer: Amerigroup Medicare	$126.76
Rate for Payer: Cash Price	$200.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.50
Rate for Payer: Iowa Total Care Managed Medicaid	$125.45
Rate for Payer: Medical Associates Commercial	$188.25
Rate for Payer: Medical Associates Managed Medicare	$125.50
Rate for Payer: Midlands Choice Commercial	$175.70
Rate for Payer: Molina Healthcare Managed Medicaid	$127.38
Rate for Payer: Molina Healthcare Managed Medicare	$127.31
Rate for Payer: Oscar Health of IA Commercial	$188.25
Rate for Payer: Partners Health Alliance Commercial	$188.25
Rate for Payer: United Healthcare Commercial	$225.90
Rate for Payer: United Healthcare Managed Medicare	$148.09

LOCKING COMPR NARROW 10 HOLE / L 187MM

Facility

$188.00

Service Code	CPT C1713
Hospital Charge Code	8046751
Hospital Revenue Code	278
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$169.20
Rate for Payer: Aetna of IA Commercial	$169.20
Rate for Payer: Aetna of IA Medical Rental Products	$169.20
Rate for Payer: Cash Price	$150.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$141.00
Rate for Payer: Medical Associates Commercial	$141.00
Rate for Payer: Midlands Choice Commercial	$131.60
Rate for Payer: United Healthcare Commercial	$169.20

LOCKING COMPR NARROW 10 HOLE / L 187MM

Facility

$188.00

Service Code	CPT C1713
Hospital Charge Code	8046751
Hospital Revenue Code	278
Min. Negotiated Rate	$93.96
Max. Negotiated Rate	$169.20
Rate for Payer: Aetna of IA Commercial	$169.20
Rate for Payer: Aetna of IA Medical Rental Products	$169.20
Rate for Payer: Aetna of IA Medicare	$107.16
Rate for Payer: Amerigroup Medicaid	$94.88
Rate for Payer: Amerigroup Medicare	$94.94
Rate for Payer: Cash Price	$150.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$141.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$94.00
Rate for Payer: Iowa Total Care Managed Medicaid	$93.96
Rate for Payer: Medical Associates Commercial	$141.00
Rate for Payer: Medical Associates Managed Medicare	$94.00
Rate for Payer: Midlands Choice Commercial	$131.60
Rate for Payer: Molina Healthcare Managed Medicaid	$95.41
Rate for Payer: Molina Healthcare Managed Medicare	$95.35
Rate for Payer: Oscar Health of IA Commercial	$141.00
Rate for Payer: Partners Health Alliance Commercial	$141.00
Rate for Payer: United Healthcare Commercial	$169.20
Rate for Payer: United Healthcare Managed Medicare	$110.92

LOCKING COMPR NARROW 12 HOLE / L 223MM

Facility

$239.00

Service Code	CPT C1713
Hospital Charge Code	8046752
Hospital Revenue Code	278
Min. Negotiated Rate	$119.45
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Aetna of IA Medicare	$136.23
Rate for Payer: Amerigroup Medicaid	$120.62
Rate for Payer: Amerigroup Medicare	$120.70
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$119.50
Rate for Payer: Iowa Total Care Managed Medicaid	$119.45
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Medical Associates Managed Medicare	$119.50
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: Molina Healthcare Managed Medicaid	$121.29
Rate for Payer: Molina Healthcare Managed Medicare	$121.22
Rate for Payer: Oscar Health of IA Commercial	$179.25
Rate for Payer: Partners Health Alliance Commercial	$179.25
Rate for Payer: United Healthcare Commercial	$215.10
Rate for Payer: United Healthcare Managed Medicare	$141.01

LOCKING COMPR NARROW 12 HOLE / L 223MM

Facility

$239.00

Service Code	CPT C1713
Hospital Charge Code	8046752
Hospital Revenue Code	278
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: United Healthcare Commercial	$215.10

LOCKING COMPR NARROW 14 HOLE / L 259MM

Facility

$239.00

Service Code	CPT C1713
Hospital Charge Code	8046753
Hospital Revenue Code	278
Min. Negotiated Rate	$119.45
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Aetna of IA Medicare	$136.23
Rate for Payer: Amerigroup Medicaid	$120.62
Rate for Payer: Amerigroup Medicare	$120.70
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$119.50
Rate for Payer: Iowa Total Care Managed Medicaid	$119.45
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Medical Associates Managed Medicare	$119.50
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: Molina Healthcare Managed Medicaid	$121.29
Rate for Payer: Molina Healthcare Managed Medicare	$121.22
Rate for Payer: Oscar Health of IA Commercial	$179.25
Rate for Payer: Partners Health Alliance Commercial	$179.25
Rate for Payer: United Healthcare Commercial	$215.10
Rate for Payer: United Healthcare Managed Medicare	$141.01

LOCKING COMPR NARROW 14 HOLE / L 259MM

Facility

$239.00

Service Code	CPT C1713
Hospital Charge Code	8046753
Hospital Revenue Code	278
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: United Healthcare Commercial	$215.10

LOCKING COMPR NARROW 2 HOLE / L 43MM

Facility

$160.00

Service Code	CPT C1713
Hospital Charge Code	8046743
Hospital Revenue Code	278
Min. Negotiated Rate	$79.97
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of IA Commercial	$144.00
Rate for Payer: Aetna of IA Medical Rental Products	$144.00
Rate for Payer: Aetna of IA Medicare	$91.20
Rate for Payer: Amerigroup Medicaid	$80.75
Rate for Payer: Amerigroup Medicare	$80.80
Rate for Payer: Cash Price	$128.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$80.00
Rate for Payer: Iowa Total Care Managed Medicaid	$79.97
Rate for Payer: Medical Associates Commercial	$120.00
Rate for Payer: Medical Associates Managed Medicare	$80.00
Rate for Payer: Midlands Choice Commercial	$112.00
Rate for Payer: Molina Healthcare Managed Medicaid	$81.20
Rate for Payer: Molina Healthcare Managed Medicare	$81.15
Rate for Payer: Oscar Health of IA Commercial	$120.00
Rate for Payer: Partners Health Alliance Commercial	$120.00
Rate for Payer: United Healthcare Commercial	$144.00
Rate for Payer: United Healthcare Managed Medicare	$94.40

LOCKING COMPR NARROW 2 HOLE / L 43MM

Facility

$160.00

Service Code	CPT C1713
Hospital Charge Code	8046743
Hospital Revenue Code	278
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of IA Commercial	$144.00
Rate for Payer: Aetna of IA Medical Rental Products	$144.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.00
Rate for Payer: Medical Associates Commercial	$120.00
Rate for Payer: Midlands Choice Commercial	$112.00
Rate for Payer: United Healthcare Commercial	$144.00

LOCKING COMPR NARROW 3 HOLE / L 61MM

Facility

$160.00

Service Code	CPT C1713
Hospital Charge Code	8046744
Hospital Revenue Code	278
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of IA Commercial	$144.00
Rate for Payer: Aetna of IA Medical Rental Products	$144.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.00
Rate for Payer: Medical Associates Commercial	$120.00
Rate for Payer: Midlands Choice Commercial	$112.00
Rate for Payer: United Healthcare Commercial	$144.00

LOCKING COMPR NARROW 3 HOLE / L 61MM

Facility

$160.00

Service Code	CPT C1713
Hospital Charge Code	8046744
Hospital Revenue Code	278
Min. Negotiated Rate	$79.97
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of IA Commercial	$144.00
Rate for Payer: Aetna of IA Medical Rental Products	$144.00
Rate for Payer: Aetna of IA Medicare	$91.20
Rate for Payer: Amerigroup Medicaid	$80.75
Rate for Payer: Amerigroup Medicare	$80.80
Rate for Payer: Cash Price	$128.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$80.00
Rate for Payer: Iowa Total Care Managed Medicaid	$79.97
Rate for Payer: Medical Associates Commercial	$120.00
Rate for Payer: Medical Associates Managed Medicare	$80.00
Rate for Payer: Midlands Choice Commercial	$112.00
Rate for Payer: Molina Healthcare Managed Medicaid	$81.20
Rate for Payer: Molina Healthcare Managed Medicare	$81.15
Rate for Payer: Oscar Health of IA Commercial	$120.00
Rate for Payer: Partners Health Alliance Commercial	$120.00
Rate for Payer: United Healthcare Commercial	$144.00
Rate for Payer: United Healthcare Managed Medicare	$94.40

LOCKING COMPR NARROW 4 HOLE / L 79MM

Facility

$150.00

Service Code	CPT C1713
Hospital Charge Code	8046745
Hospital Revenue Code	278
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: United Healthcare Commercial	$135.00

LOCKING COMPR NARROW 4 HOLE / L 79MM

Facility

$150.00

Service Code	CPT C1713
Hospital Charge Code	8046745
Hospital Revenue Code	278
Min. Negotiated Rate	$74.97
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Aetna of IA Medicare	$85.50
Rate for Payer: Amerigroup Medicaid	$75.70
Rate for Payer: Amerigroup Medicare	$75.75
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$75.00
Rate for Payer: Iowa Total Care Managed Medicaid	$74.97
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Medical Associates Managed Medicare	$75.00
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: Molina Healthcare Managed Medicaid	$76.12
Rate for Payer: Molina Healthcare Managed Medicare	$76.08
Rate for Payer: Oscar Health of IA Commercial	$112.50
Rate for Payer: Partners Health Alliance Commercial	$112.50
Rate for Payer: United Healthcare Commercial	$135.00
Rate for Payer: United Healthcare Managed Medicare	$88.50

LOCKING COMPR NARROW 5 HOLE / L 97MM

Facility

$150.00

Service Code	CPT C1713
Hospital Charge Code	8046746
Hospital Revenue Code	278
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: United Healthcare Commercial	$135.00

Know your out-of-pocket cost for care.

All Charges