Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

PLATELET COUNT

Facility

$48.00

Service Code	CPT 85049
Hospital Charge Code	2182297
Hospital Revenue Code	305
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of IA Commercial	$43.20
Rate for Payer: Aetna of IA Medical Rental Products	$43.20
Rate for Payer: Cash Price	$38.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$36.00
Rate for Payer: Medical Associates Commercial	$36.00
Rate for Payer: Midlands Choice Commercial	$33.60
Rate for Payer: United Healthcare Commercial	$43.20

PLATE LOCKING AXSOS RECON 10 HOLE L120

Facility

$635.00

Service Code	HCPCS C1713
Hospital Charge Code	8046738
Hospital Revenue Code	278
Min. Negotiated Rate	$285.75
Max. Negotiated Rate	$571.50
Rate for Payer: Aetna of IA Commercial	$571.50
Rate for Payer: Aetna of IA Medical Rental Products	$571.50
Rate for Payer: Aetna of IA Medicare	$361.95
Rate for Payer: Amerigroup Medicaid	$366.27
Rate for Payer: Amerigroup Medicare	$288.61
Rate for Payer: Cash Price	$508.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$476.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$285.75
Rate for Payer: Iowa Total Care Managed Medicaid	$362.71
Rate for Payer: Medical Associates Commercial	$476.25
Rate for Payer: Medical Associates Managed Medicare	$285.75
Rate for Payer: Midlands Choice Commercial	$444.50
Rate for Payer: Molina Healthcare Managed Medicaid	$368.05
Rate for Payer: Partners Health Alliance Commercial	$328.61
Rate for Payer: United Healthcare Commercial	$571.50
Rate for Payer: United Healthcare Managed Medicare	$374.65

PLATE LOCKING AXSOS RECON 10 HOLE L120

Facility

$635.00

Service Code	HCPCS C1713
Hospital Charge Code	8046738
Hospital Revenue Code	278
Min. Negotiated Rate	$444.50
Max. Negotiated Rate	$571.50
Rate for Payer: Aetna of IA Commercial	$571.50
Rate for Payer: Aetna of IA Medical Rental Products	$571.50
Rate for Payer: Cash Price	$508.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$476.25
Rate for Payer: Medical Associates Commercial	$476.25
Rate for Payer: Midlands Choice Commercial	$444.50
Rate for Payer: United Healthcare Commercial	$571.50

PLATE LOCKING AXSOS RECON 4 HOLE L48

Facility

$477.00

Service Code	HCPCS C1713
Hospital Charge Code	8046735
Hospital Revenue Code	278
Min. Negotiated Rate	$214.65
Max. Negotiated Rate	$429.30
Rate for Payer: Aetna of IA Commercial	$429.30
Rate for Payer: Aetna of IA Medical Rental Products	$429.30
Rate for Payer: Aetna of IA Medicare	$271.89
Rate for Payer: Amerigroup Medicaid	$275.13
Rate for Payer: Amerigroup Medicare	$216.80
Rate for Payer: Cash Price	$381.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$357.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$214.65
Rate for Payer: Iowa Total Care Managed Medicaid	$272.46
Rate for Payer: Medical Associates Commercial	$357.75
Rate for Payer: Medical Associates Managed Medicare	$214.65
Rate for Payer: Midlands Choice Commercial	$333.90
Rate for Payer: Molina Healthcare Managed Medicaid	$276.47
Rate for Payer: Partners Health Alliance Commercial	$246.85
Rate for Payer: United Healthcare Commercial	$429.30
Rate for Payer: United Healthcare Managed Medicare	$281.43

PLATE LOCKING AXSOS RECON 4 HOLE L48

Facility

$477.00

Service Code	HCPCS C1713
Hospital Charge Code	8046735
Hospital Revenue Code	278
Min. Negotiated Rate	$333.90
Max. Negotiated Rate	$429.30
Rate for Payer: Aetna of IA Commercial	$429.30
Rate for Payer: Aetna of IA Medical Rental Products	$429.30
Rate for Payer: Cash Price	$381.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$357.75
Rate for Payer: Medical Associates Commercial	$357.75
Rate for Payer: Midlands Choice Commercial	$333.90
Rate for Payer: United Healthcare Commercial	$429.30

PLATE LOCKING AXSOS RECON 6 HOLE L172

Facility

$561.00

Service Code	HCPCS C1713
Hospital Charge Code	8046736
Hospital Revenue Code	278
Min. Negotiated Rate	$392.70
Max. Negotiated Rate	$504.90
Rate for Payer: Aetna of IA Commercial	$504.90
Rate for Payer: Aetna of IA Medical Rental Products	$504.90
Rate for Payer: Cash Price	$448.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$420.75
Rate for Payer: Medical Associates Commercial	$420.75
Rate for Payer: Midlands Choice Commercial	$392.70
Rate for Payer: United Healthcare Commercial	$504.90

PLATE LOCKING AXSOS RECON 6 HOLE L172

Facility

$561.00

Service Code	HCPCS C1713
Hospital Charge Code	8046736
Hospital Revenue Code	278
Min. Negotiated Rate	$252.45
Max. Negotiated Rate	$504.90
Rate for Payer: Aetna of IA Commercial	$504.90
Rate for Payer: Aetna of IA Medical Rental Products	$504.90
Rate for Payer: Aetna of IA Medicare	$319.77
Rate for Payer: Amerigroup Medicaid	$323.58
Rate for Payer: Amerigroup Medicare	$254.97
Rate for Payer: Cash Price	$448.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$420.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$252.45
Rate for Payer: Iowa Total Care Managed Medicaid	$320.44
Rate for Payer: Medical Associates Commercial	$420.75
Rate for Payer: Medical Associates Managed Medicare	$252.45
Rate for Payer: Midlands Choice Commercial	$392.70
Rate for Payer: Molina Healthcare Managed Medicaid	$325.16
Rate for Payer: Partners Health Alliance Commercial	$290.32
Rate for Payer: United Healthcare Commercial	$504.90
Rate for Payer: United Healthcare Managed Medicare	$330.99

PLATE LOCKING AXSOS RECON 8 HOLE L96

Facility

$615.00

Service Code	HCPCS C1713
Hospital Charge Code	8046737
Hospital Revenue Code	278
Min. Negotiated Rate	$430.50
Max. Negotiated Rate	$553.50
Rate for Payer: Aetna of IA Commercial	$553.50
Rate for Payer: Aetna of IA Medical Rental Products	$553.50
Rate for Payer: Cash Price	$492.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$461.25
Rate for Payer: Medical Associates Commercial	$461.25
Rate for Payer: Midlands Choice Commercial	$430.50
Rate for Payer: United Healthcare Commercial	$553.50

PLATE LOCKING AXSOS RECON 8 HOLE L96

Facility

$615.00

Service Code	HCPCS C1713
Hospital Charge Code	8046737
Hospital Revenue Code	278
Min. Negotiated Rate	$276.75
Max. Negotiated Rate	$553.50
Rate for Payer: Aetna of IA Commercial	$553.50
Rate for Payer: Aetna of IA Medical Rental Products	$553.50
Rate for Payer: Aetna of IA Medicare	$350.55
Rate for Payer: Amerigroup Medicaid	$354.73
Rate for Payer: Amerigroup Medicare	$279.52
Rate for Payer: Cash Price	$492.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$461.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$276.75
Rate for Payer: Iowa Total Care Managed Medicaid	$351.29
Rate for Payer: Medical Associates Commercial	$461.25
Rate for Payer: Medical Associates Managed Medicare	$276.75
Rate for Payer: Midlands Choice Commercial	$430.50
Rate for Payer: Molina Healthcare Managed Medicaid	$356.45
Rate for Payer: Partners Health Alliance Commercial	$318.26
Rate for Payer: United Healthcare Commercial	$553.50
Rate for Payer: United Healthcare Managed Medicare	$362.85

PLATE LOCKING DELTOID AVULSION, SS, 5H

Facility

$1,114.00

Service Code	HCPCS C1713
Hospital Charge Code	8047167
Hospital Revenue Code	278
Min. Negotiated Rate	$501.30
Max. Negotiated Rate	$1,002.60
Rate for Payer: Aetna of IA Commercial	$1,002.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,002.60
Rate for Payer: Aetna of IA Medicare	$634.98
Rate for Payer: Amerigroup Medicaid	$642.56
Rate for Payer: Amerigroup Medicare	$506.31
Rate for Payer: Cash Price	$891.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$835.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$501.30
Rate for Payer: Iowa Total Care Managed Medicaid	$636.32
Rate for Payer: Medical Associates Commercial	$835.50
Rate for Payer: Medical Associates Managed Medicare	$501.30
Rate for Payer: Midlands Choice Commercial	$779.80
Rate for Payer: Molina Healthcare Managed Medicaid	$645.67
Rate for Payer: Partners Health Alliance Commercial	$576.50
Rate for Payer: United Healthcare Commercial	$1,002.60
Rate for Payer: United Healthcare Managed Medicare	$657.26

PLATE LOCKING DELTOID AVULSION, SS, 5H

Facility

$1,114.00

Service Code	HCPCS C1713
Hospital Charge Code	8047167
Hospital Revenue Code	278
Min. Negotiated Rate	$779.80
Max. Negotiated Rate	$1,002.60
Rate for Payer: Aetna of IA Commercial	$1,002.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,002.60
Rate for Payer: Cash Price	$891.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$835.50
Rate for Payer: Medical Associates Commercial	$835.50
Rate for Payer: Midlands Choice Commercial	$779.80
Rate for Payer: United Healthcare Commercial	$1,002.60

PLATE LOCKING DELTOID AVULSION, SS, 7H

Facility

$1,215.00

Service Code	HCPCS C1713
Hospital Charge Code	8047168
Hospital Revenue Code	278
Min. Negotiated Rate	$546.75
Max. Negotiated Rate	$1,093.50
Rate for Payer: Aetna of IA Commercial	$1,093.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,093.50
Rate for Payer: Aetna of IA Medicare	$692.55
Rate for Payer: Amerigroup Medicaid	$700.81
Rate for Payer: Amerigroup Medicare	$552.22
Rate for Payer: Cash Price	$972.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$911.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$546.75
Rate for Payer: Iowa Total Care Managed Medicaid	$694.01
Rate for Payer: Medical Associates Commercial	$911.25
Rate for Payer: Medical Associates Managed Medicare	$546.75
Rate for Payer: Midlands Choice Commercial	$850.50
Rate for Payer: Molina Healthcare Managed Medicaid	$704.21
Rate for Payer: Partners Health Alliance Commercial	$628.76
Rate for Payer: United Healthcare Commercial	$1,093.50
Rate for Payer: United Healthcare Managed Medicare	$716.85

PLATE LOCKING DELTOID AVULSION, SS, 7H

Facility

$1,215.00

Service Code	HCPCS C1713
Hospital Charge Code	8047168
Hospital Revenue Code	278
Min. Negotiated Rate	$850.50
Max. Negotiated Rate	$1,093.50
Rate for Payer: Aetna of IA Commercial	$1,093.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,093.50
Rate for Payer: Cash Price	$972.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$911.25
Rate for Payer: Medical Associates Commercial	$911.25
Rate for Payer: Midlands Choice Commercial	$850.50
Rate for Payer: United Healthcare Commercial	$1,093.50

PLATE LOCKING DISTAL FIBULA, SS,LEFT, 4H

Facility

$743.00

Service Code	HCPCS C1713
Hospital Charge Code	8047152
Hospital Revenue Code	278
Min. Negotiated Rate	$520.10
Max. Negotiated Rate	$668.70
Rate for Payer: Aetna of IA Commercial	$668.70
Rate for Payer: Aetna of IA Medical Rental Products	$668.70
Rate for Payer: Cash Price	$594.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$557.25
Rate for Payer: Medical Associates Commercial	$557.25
Rate for Payer: Midlands Choice Commercial	$520.10
Rate for Payer: United Healthcare Commercial	$668.70

PLATE LOCKING DISTAL FIBULA, SS,LEFT, 4H

Facility

$743.00

Service Code	HCPCS C1713
Hospital Charge Code	8047152
Hospital Revenue Code	278
Min. Negotiated Rate	$334.35
Max. Negotiated Rate	$668.70
Rate for Payer: Aetna of IA Commercial	$668.70
Rate for Payer: Aetna of IA Medical Rental Products	$668.70
Rate for Payer: Aetna of IA Medicare	$423.51
Rate for Payer: Amerigroup Medicaid	$428.56
Rate for Payer: Amerigroup Medicare	$337.69
Rate for Payer: Cash Price	$594.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$557.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$334.35
Rate for Payer: Iowa Total Care Managed Medicaid	$424.40
Rate for Payer: Medical Associates Commercial	$557.25
Rate for Payer: Medical Associates Managed Medicare	$334.35
Rate for Payer: Midlands Choice Commercial	$520.10
Rate for Payer: Molina Healthcare Managed Medicaid	$430.64
Rate for Payer: Partners Health Alliance Commercial	$384.50
Rate for Payer: United Healthcare Commercial	$668.70
Rate for Payer: United Healthcare Managed Medicare	$438.37

PLATE LOCKING DISTAL FIBULA, SS,LEFT, 5H

Facility

$878.00

Service Code	HCPCS C1713
Hospital Charge Code	8047153
Hospital Revenue Code	278
Min. Negotiated Rate	$395.10
Max. Negotiated Rate	$790.20
Rate for Payer: Aetna of IA Commercial	$790.20
Rate for Payer: Aetna of IA Medical Rental Products	$790.20
Rate for Payer: Aetna of IA Medicare	$500.46
Rate for Payer: Amerigroup Medicaid	$506.43
Rate for Payer: Amerigroup Medicare	$399.05
Rate for Payer: Cash Price	$702.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$658.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$395.10
Rate for Payer: Iowa Total Care Managed Medicaid	$501.51
Rate for Payer: Medical Associates Commercial	$658.50
Rate for Payer: Medical Associates Managed Medicare	$395.10
Rate for Payer: Midlands Choice Commercial	$614.60
Rate for Payer: Molina Healthcare Managed Medicaid	$508.89
Rate for Payer: Partners Health Alliance Commercial	$454.37
Rate for Payer: United Healthcare Commercial	$790.20
Rate for Payer: United Healthcare Managed Medicare	$518.02

PLATE LOCKING DISTAL FIBULA, SS,LEFT, 5H

Facility

$878.00

Service Code	HCPCS C1713
Hospital Charge Code	8047153
Hospital Revenue Code	278
Min. Negotiated Rate	$614.60
Max. Negotiated Rate	$790.20
Rate for Payer: Aetna of IA Commercial	$790.20
Rate for Payer: Aetna of IA Medical Rental Products	$790.20
Rate for Payer: Cash Price	$702.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$658.50
Rate for Payer: Medical Associates Commercial	$658.50
Rate for Payer: Midlands Choice Commercial	$614.60
Rate for Payer: United Healthcare Commercial	$790.20

PLATE LOCKING DISTAL FIBULA, SS,LEFT, 6H

Facility

$979.00

Service Code	HCPCS C1713
Hospital Charge Code	8047154
Hospital Revenue Code	278
Min. Negotiated Rate	$440.55
Max. Negotiated Rate	$881.10
Rate for Payer: Aetna of IA Commercial	$881.10
Rate for Payer: Aetna of IA Medical Rental Products	$881.10
Rate for Payer: Aetna of IA Medicare	$558.03
Rate for Payer: Amerigroup Medicaid	$564.69
Rate for Payer: Amerigroup Medicare	$444.96
Rate for Payer: Cash Price	$783.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$734.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$440.55
Rate for Payer: Iowa Total Care Managed Medicaid	$559.20
Rate for Payer: Medical Associates Commercial	$734.25
Rate for Payer: Medical Associates Managed Medicare	$440.55
Rate for Payer: Midlands Choice Commercial	$685.30
Rate for Payer: Molina Healthcare Managed Medicaid	$567.43
Rate for Payer: Partners Health Alliance Commercial	$506.63
Rate for Payer: United Healthcare Commercial	$881.10
Rate for Payer: United Healthcare Managed Medicare	$577.61

PLATE LOCKING DISTAL FIBULA, SS,LEFT, 6H

Facility

$979.00

Service Code	HCPCS C1713
Hospital Charge Code	8047154
Hospital Revenue Code	278
Min. Negotiated Rate	$685.30
Max. Negotiated Rate	$881.10
Rate for Payer: Aetna of IA Commercial	$881.10
Rate for Payer: Aetna of IA Medical Rental Products	$881.10
Rate for Payer: Cash Price	$783.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$734.25
Rate for Payer: Medical Associates Commercial	$734.25
Rate for Payer: Midlands Choice Commercial	$685.30
Rate for Payer: United Healthcare Commercial	$881.10

PLATE LOCKING DISTAL FIBULA, SS,LEFT, 8H

Facility

$1,073.00

Service Code	HCPCS C1713
Hospital Charge Code	8047155
Hospital Revenue Code	278
Min. Negotiated Rate	$482.85
Max. Negotiated Rate	$965.70
Rate for Payer: Aetna of IA Commercial	$965.70
Rate for Payer: Aetna of IA Medical Rental Products	$965.70
Rate for Payer: Aetna of IA Medicare	$611.61
Rate for Payer: Amerigroup Medicaid	$618.91
Rate for Payer: Amerigroup Medicare	$487.68
Rate for Payer: Cash Price	$858.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$804.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$482.85
Rate for Payer: Iowa Total Care Managed Medicaid	$612.90
Rate for Payer: Medical Associates Commercial	$804.75
Rate for Payer: Medical Associates Managed Medicare	$482.85
Rate for Payer: Midlands Choice Commercial	$751.10
Rate for Payer: Molina Healthcare Managed Medicaid	$621.91
Rate for Payer: Partners Health Alliance Commercial	$555.28
Rate for Payer: United Healthcare Commercial	$965.70
Rate for Payer: United Healthcare Managed Medicare	$633.07

PLATE LOCKING DISTAL FIBULA, SS,LEFT, 8H

Facility

$1,073.00

Service Code	HCPCS C1713
Hospital Charge Code	8047155
Hospital Revenue Code	278
Min. Negotiated Rate	$751.10
Max. Negotiated Rate	$965.70
Rate for Payer: Aetna of IA Commercial	$965.70
Rate for Payer: Aetna of IA Medical Rental Products	$965.70
Rate for Payer: Cash Price	$858.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$804.75
Rate for Payer: Medical Associates Commercial	$804.75
Rate for Payer: Midlands Choice Commercial	$751.10
Rate for Payer: United Healthcare Commercial	$965.70

PLATE LOCKING DISTAL FIBULA,SS,RIGHT, 4H

Facility

$743.00

Service Code	HCPCS C1713
Hospital Charge Code	8047156
Hospital Revenue Code	278
Min. Negotiated Rate	$334.35
Max. Negotiated Rate	$668.70
Rate for Payer: Aetna of IA Commercial	$668.70
Rate for Payer: Aetna of IA Medical Rental Products	$668.70
Rate for Payer: Aetna of IA Medicare	$423.51
Rate for Payer: Amerigroup Medicaid	$428.56
Rate for Payer: Amerigroup Medicare	$337.69
Rate for Payer: Cash Price	$594.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$557.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$334.35
Rate for Payer: Iowa Total Care Managed Medicaid	$424.40
Rate for Payer: Medical Associates Commercial	$557.25
Rate for Payer: Medical Associates Managed Medicare	$334.35
Rate for Payer: Midlands Choice Commercial	$520.10
Rate for Payer: Molina Healthcare Managed Medicaid	$430.64
Rate for Payer: Partners Health Alliance Commercial	$384.50
Rate for Payer: United Healthcare Commercial	$668.70
Rate for Payer: United Healthcare Managed Medicare	$438.37

PLATE LOCKING DISTAL FIBULA,SS,RIGHT, 4H

Facility

$743.00

Service Code	HCPCS C1713
Hospital Charge Code	8047156
Hospital Revenue Code	278
Min. Negotiated Rate	$520.10
Max. Negotiated Rate	$668.70
Rate for Payer: Aetna of IA Commercial	$668.70
Rate for Payer: Aetna of IA Medical Rental Products	$668.70
Rate for Payer: Cash Price	$594.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$557.25
Rate for Payer: Medical Associates Commercial	$557.25
Rate for Payer: Midlands Choice Commercial	$520.10
Rate for Payer: United Healthcare Commercial	$668.70

PLATE LOCKING DISTAL FIBULA,SS,RIGHT, 5H

Facility

$878.00

Service Code	HCPCS C1713
Hospital Charge Code	8047157
Hospital Revenue Code	278
Min. Negotiated Rate	$395.10
Max. Negotiated Rate	$790.20
Rate for Payer: Aetna of IA Commercial	$790.20
Rate for Payer: Aetna of IA Medical Rental Products	$790.20
Rate for Payer: Aetna of IA Medicare	$500.46
Rate for Payer: Amerigroup Medicaid	$506.43
Rate for Payer: Amerigroup Medicare	$399.05
Rate for Payer: Cash Price	$702.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$658.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$395.10
Rate for Payer: Iowa Total Care Managed Medicaid	$501.51
Rate for Payer: Medical Associates Commercial	$658.50
Rate for Payer: Medical Associates Managed Medicare	$395.10
Rate for Payer: Midlands Choice Commercial	$614.60
Rate for Payer: Molina Healthcare Managed Medicaid	$508.89
Rate for Payer: Partners Health Alliance Commercial	$454.37
Rate for Payer: United Healthcare Commercial	$790.20
Rate for Payer: United Healthcare Managed Medicare	$518.02

PLATE LOCKING DISTAL FIBULA,SS,RIGHT, 5H

Facility

$878.00

Service Code	HCPCS C1713
Hospital Charge Code	8047157
Hospital Revenue Code	278
Min. Negotiated Rate	$614.60
Max. Negotiated Rate	$790.20
Rate for Payer: Aetna of IA Commercial	$790.20
Rate for Payer: Aetna of IA Medical Rental Products	$790.20
Rate for Payer: Cash Price	$702.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$658.50
Rate for Payer: Medical Associates Commercial	$658.50
Rate for Payer: Midlands Choice Commercial	$614.60
Rate for Payer: United Healthcare Commercial	$790.20

Know your out-of-pocket cost for care.

All Charges