Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ACCESSORY KIT FOR INTELLIS ADAPTIVESTIM

Facility

$94.00

Service Code	HCPCS C1778
Hospital Charge Code	8557556
Hospital Revenue Code	278
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of IA Commercial	$84.60
Rate for Payer: Aetna of IA Medical Rental Products	$84.60
Rate for Payer: Aetna of IA Medicare	$53.58
Rate for Payer: Amerigroup Medicaid	$54.22
Rate for Payer: Amerigroup Medicare	$42.72
Rate for Payer: Cash Price	$75.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$42.30
Rate for Payer: Iowa Total Care Managed Medicaid	$53.69
Rate for Payer: Medical Associates Commercial	$70.50
Rate for Payer: Medical Associates Managed Medicare	$42.30
Rate for Payer: Midlands Choice Commercial	$65.80
Rate for Payer: Molina Healthcare Managed Medicaid	$54.48
Rate for Payer: Partners Health Alliance Commercial	$48.64
Rate for Payer: United Healthcare Commercial	$84.60
Rate for Payer: United Healthcare Managed Medicare	$55.46

ACCESSORY KIT FOR INTELLIS ADAPTIVESTIM

Facility

$94.00

Service Code	HCPCS C1778
Hospital Charge Code	8557556
Hospital Revenue Code	278
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of IA Commercial	$84.60
Rate for Payer: Aetna of IA Medical Rental Products	$84.60
Rate for Payer: Cash Price	$75.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.50
Rate for Payer: Medical Associates Commercial	$70.50
Rate for Payer: Midlands Choice Commercial	$65.80
Rate for Payer: United Healthcare Commercial	$84.60

acellular dermal graft 15mm x 140mm x1.5

Facility

$3,859.00

Service Code	HCPCS Q4100
Hospital Charge Code	8832409
Hospital Revenue Code	278
Min. Negotiated Rate	$2,701.30
Max. Negotiated Rate	$3,473.10
Rate for Payer: Aetna of IA Commercial	$3,473.10
Rate for Payer: Aetna of IA Medical Rental Products	$3,473.10
Rate for Payer: Cash Price	$3,087.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,894.25
Rate for Payer: Medical Associates Commercial	$2,894.25
Rate for Payer: Midlands Choice Commercial	$2,701.30
Rate for Payer: United Healthcare Commercial	$3,473.10

acellular dermal graft 15mm x 140mm x1.5

Facility

$3,859.00

Service Code	HCPCS Q4100
Hospital Charge Code	8832409
Hospital Revenue Code	278
Min. Negotiated Rate	$1,736.55
Max. Negotiated Rate	$3,473.10
Rate for Payer: Aetna of IA Commercial	$3,473.10
Rate for Payer: Aetna of IA Medical Rental Products	$3,473.10
Rate for Payer: Aetna of IA Medicare	$2,199.63
Rate for Payer: Amerigroup Medicaid	$2,225.87
Rate for Payer: Amerigroup Medicare	$1,753.92
Rate for Payer: Cash Price	$3,087.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,894.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,736.55
Rate for Payer: Iowa Total Care Managed Medicaid	$2,204.26
Rate for Payer: Medical Associates Commercial	$2,894.25
Rate for Payer: Medical Associates Managed Medicare	$1,736.55
Rate for Payer: Midlands Choice Commercial	$2,701.30
Rate for Payer: Molina Healthcare Managed Medicaid	$2,236.68
Rate for Payer: Partners Health Alliance Commercial	$1,997.03
Rate for Payer: United Healthcare Commercial	$3,473.10
Rate for Payer: United Healthcare Managed Medicare	$2,276.81

ACETABULAR DOME HOLE PLUG

Facility

$269.00

Service Code	HCPCS C1713
Hospital Charge Code	8046375
Hospital Revenue Code	278
Min. Negotiated Rate	$121.05
Max. Negotiated Rate	$242.10
Rate for Payer: Aetna of IA Commercial	$242.10
Rate for Payer: Aetna of IA Medical Rental Products	$242.10
Rate for Payer: Aetna of IA Medicare	$153.33
Rate for Payer: Amerigroup Medicaid	$155.16
Rate for Payer: Amerigroup Medicare	$122.26
Rate for Payer: Cash Price	$215.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$201.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$121.05
Rate for Payer: Iowa Total Care Managed Medicaid	$153.65
Rate for Payer: Medical Associates Commercial	$201.75
Rate for Payer: Medical Associates Managed Medicare	$121.05
Rate for Payer: Midlands Choice Commercial	$188.30
Rate for Payer: Molina Healthcare Managed Medicaid	$155.91
Rate for Payer: Partners Health Alliance Commercial	$139.21
Rate for Payer: United Healthcare Commercial	$242.10
Rate for Payer: United Healthcare Managed Medicare	$158.71

ACETABULAR DOME HOLE PLUG

Facility

$269.00

Service Code	HCPCS C1713
Hospital Charge Code	8046375
Hospital Revenue Code	278
Min. Negotiated Rate	$188.30
Max. Negotiated Rate	$242.10
Rate for Payer: Aetna of IA Commercial	$242.10
Rate for Payer: Aetna of IA Medical Rental Products	$242.10
Rate for Payer: Cash Price	$215.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$201.75
Rate for Payer: Medical Associates Commercial	$201.75
Rate for Payer: Midlands Choice Commercial	$188.30
Rate for Payer: United Healthcare Commercial	$242.10

ACETABULAR SHELL 54MM

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046817
Hospital Revenue Code	278
Min. Negotiated Rate	$1,961.10
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Aetna of IA Medicare	$2,484.06
Rate for Payer: Amerigroup Medicaid	$2,513.69
Rate for Payer: Amerigroup Medicare	$1,980.71
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,961.10
Rate for Payer: Iowa Total Care Managed Medicaid	$2,489.29
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Medical Associates Managed Medicare	$1,961.10
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,525.90
Rate for Payer: Partners Health Alliance Commercial	$2,255.26
Rate for Payer: United Healthcare Commercial	$3,922.20
Rate for Payer: United Healthcare Managed Medicare	$2,571.22

ACETABULAR SHELL 54MM

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046817
Hospital Revenue Code	278
Min. Negotiated Rate	$3,050.60
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: United Healthcare Commercial	$3,922.20

ACETABULAR SHELL 54MM CLUSTER F

Facility

$4,334.00

Service Code	HCPCS L8699
Hospital Charge Code	8046820
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Aetna of IA Commercial	$3,900.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,900.60
Rate for Payer: Aetna of IA Medicare	$2,470.38
Rate for Payer: Amerigroup Medicaid	$2,499.85
Rate for Payer: Amerigroup Medicare	$1,969.80
Rate for Payer: Cash Price	$3,467.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,250.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,950.30
Rate for Payer: Iowa Total Care Managed Medicaid	$2,475.58
Rate for Payer: Medical Associates Commercial	$3,250.50
Rate for Payer: Medical Associates Managed Medicare	$1,950.30
Rate for Payer: Midlands Choice Commercial	$3,033.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2,511.99
Rate for Payer: Partners Health Alliance Commercial	$2,242.84
Rate for Payer: United Healthcare Commercial	$3,900.60
Rate for Payer: United Healthcare Managed Medicare	$2,557.06

ACETABULAR SHELL 54MM CLUSTER F

Facility

$4,334.00

Service Code	HCPCS L8699
Hospital Charge Code	8046820
Hospital Revenue Code	278
Min. Negotiated Rate	$3,033.80
Max. Negotiated Rate	$3,900.60
Rate for Payer: Aetna of IA Commercial	$3,900.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,900.60
Rate for Payer: Cash Price	$3,467.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,250.50
Rate for Payer: Medical Associates Commercial	$3,250.50
Rate for Payer: Midlands Choice Commercial	$3,033.80
Rate for Payer: United Healthcare Commercial	$3,900.60

ACETABULAR SHELL 56MM CLUSTER

Facility

$4,334.00

Service Code	HCPCS L8699
Hospital Charge Code	8046821
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Aetna of IA Commercial	$3,900.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,900.60
Rate for Payer: Aetna of IA Medicare	$2,470.38
Rate for Payer: Amerigroup Medicaid	$2,499.85
Rate for Payer: Amerigroup Medicare	$1,969.80
Rate for Payer: Cash Price	$3,467.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,250.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,950.30
Rate for Payer: Iowa Total Care Managed Medicaid	$2,475.58
Rate for Payer: Medical Associates Commercial	$3,250.50
Rate for Payer: Medical Associates Managed Medicare	$1,950.30
Rate for Payer: Midlands Choice Commercial	$3,033.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2,511.99
Rate for Payer: Partners Health Alliance Commercial	$2,242.84
Rate for Payer: United Healthcare Commercial	$3,900.60
Rate for Payer: United Healthcare Managed Medicare	$2,557.06

ACETABULAR SHELL 56MM CLUSTER

Facility

$4,334.00

Service Code	HCPCS L8699
Hospital Charge Code	8046821
Hospital Revenue Code	278
Min. Negotiated Rate	$3,033.80
Max. Negotiated Rate	$3,900.60
Rate for Payer: Aetna of IA Commercial	$3,900.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,900.60
Rate for Payer: Cash Price	$3,467.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,250.50
Rate for Payer: Medical Associates Commercial	$3,250.50
Rate for Payer: Midlands Choice Commercial	$3,033.80
Rate for Payer: United Healthcare Commercial	$3,900.60

ACETABULAR SHELL 58MM CLUSTER

Facility

$4,334.00

Service Code	HCPCS L8699
Hospital Charge Code	8046822
Hospital Revenue Code	278
Min. Negotiated Rate	$1,950.30
Max. Negotiated Rate	$3,900.60
Rate for Payer: Aetna of IA Commercial	$3,900.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,900.60
Rate for Payer: Aetna of IA Medicare	$2,470.38
Rate for Payer: Amerigroup Medicaid	$2,499.85
Rate for Payer: Amerigroup Medicare	$1,969.80
Rate for Payer: Cash Price	$3,467.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,250.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,950.30
Rate for Payer: Iowa Total Care Managed Medicaid	$2,475.58
Rate for Payer: Medical Associates Commercial	$3,250.50
Rate for Payer: Medical Associates Managed Medicare	$1,950.30
Rate for Payer: Midlands Choice Commercial	$3,033.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2,511.99
Rate for Payer: Partners Health Alliance Commercial	$2,242.84
Rate for Payer: United Healthcare Commercial	$3,900.60
Rate for Payer: United Healthcare Managed Medicare	$2,557.06

ACETABULAR SHELL 58MM CLUSTER

Facility

$4,334.00

Service Code	HCPCS L8699
Hospital Charge Code	8046822
Hospital Revenue Code	278
Min. Negotiated Rate	$3,033.80
Max. Negotiated Rate	$3,900.60
Rate for Payer: Aetna of IA Commercial	$3,900.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,900.60
Rate for Payer: Cash Price	$3,467.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,250.50
Rate for Payer: Medical Associates Commercial	$3,250.50
Rate for Payer: Midlands Choice Commercial	$3,033.80
Rate for Payer: United Healthcare Commercial	$3,900.60

ACETABULAR SHELL 60MM CLUSTER

Facility

$4,473.00

Service Code	HCPCS L8699
Hospital Charge Code	8046823
Hospital Revenue Code	278
Min. Negotiated Rate	$2,012.85
Max. Negotiated Rate	$4,025.70
Rate for Payer: Aetna of IA Commercial	$4,025.70
Rate for Payer: Aetna of IA Medical Rental Products	$4,025.70
Rate for Payer: Aetna of IA Medicare	$2,549.61
Rate for Payer: Amerigroup Medicaid	$2,580.03
Rate for Payer: Amerigroup Medicare	$2,032.98
Rate for Payer: Cash Price	$3,578.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,354.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,012.85
Rate for Payer: Iowa Total Care Managed Medicaid	$2,554.98
Rate for Payer: Medical Associates Commercial	$3,354.75
Rate for Payer: Medical Associates Managed Medicare	$2,012.85
Rate for Payer: Midlands Choice Commercial	$3,131.10
Rate for Payer: Molina Healthcare Managed Medicaid	$2,592.55
Rate for Payer: Partners Health Alliance Commercial	$2,314.78
Rate for Payer: United Healthcare Commercial	$4,025.70
Rate for Payer: United Healthcare Managed Medicare	$2,639.07

ACETABULAR SHELL 60MM CLUSTER

Facility

$4,473.00

Service Code	HCPCS L8699
Hospital Charge Code	8046823
Hospital Revenue Code	278
Min. Negotiated Rate	$3,131.10
Max. Negotiated Rate	$4,025.70
Rate for Payer: Aetna of IA Commercial	$4,025.70
Rate for Payer: Aetna of IA Medical Rental Products	$4,025.70
Rate for Payer: Cash Price	$3,578.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,354.75
Rate for Payer: Medical Associates Commercial	$3,354.75
Rate for Payer: Midlands Choice Commercial	$3,131.10
Rate for Payer: United Healthcare Commercial	$4,025.70

ACETABULARSHELL SOLID BACK 58MM

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046819
Hospital Revenue Code	278
Min. Negotiated Rate	$1,961.10
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Aetna of IA Medicare	$2,484.06
Rate for Payer: Amerigroup Medicaid	$2,513.69
Rate for Payer: Amerigroup Medicare	$1,980.71
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,961.10
Rate for Payer: Iowa Total Care Managed Medicaid	$2,489.29
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Medical Associates Managed Medicare	$1,961.10
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,525.90
Rate for Payer: Partners Health Alliance Commercial	$2,255.26
Rate for Payer: United Healthcare Commercial	$3,922.20
Rate for Payer: United Healthcare Managed Medicare	$2,571.22

ACETABULARSHELL SOLID BACK 58MM

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046819
Hospital Revenue Code	278
Min. Negotiated Rate	$3,050.60
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: United Healthcare Commercial	$3,922.20

ACETABULAR SHELL SYSTEM

Facility

$4,230.00

Service Code	HCPCS L8699
Hospital Charge Code	8046795
Hospital Revenue Code	278
Min. Negotiated Rate	$2,961.00
Max. Negotiated Rate	$3,807.00
Rate for Payer: Aetna of IA Commercial	$3,807.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,807.00
Rate for Payer: Cash Price	$3,384.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,172.50
Rate for Payer: Medical Associates Commercial	$3,172.50
Rate for Payer: Midlands Choice Commercial	$2,961.00
Rate for Payer: United Healthcare Commercial	$3,807.00

ACETABULAR SHELL SYSTEM

Facility

$4,230.00

Service Code	HCPCS L8699
Hospital Charge Code	8046795
Hospital Revenue Code	278
Min. Negotiated Rate	$1,903.50
Max. Negotiated Rate	$3,807.00
Rate for Payer: Aetna of IA Commercial	$3,807.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,807.00
Rate for Payer: Aetna of IA Medicare	$2,411.10
Rate for Payer: Amerigroup Medicaid	$2,439.86
Rate for Payer: Amerigroup Medicare	$1,922.54
Rate for Payer: Cash Price	$3,384.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,172.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,903.50
Rate for Payer: Iowa Total Care Managed Medicaid	$2,416.18
Rate for Payer: Medical Associates Commercial	$3,172.50
Rate for Payer: Medical Associates Managed Medicare	$1,903.50
Rate for Payer: Midlands Choice Commercial	$2,961.00
Rate for Payer: Molina Healthcare Managed Medicaid	$2,451.71
Rate for Payer: Partners Health Alliance Commercial	$2,189.02
Rate for Payer: United Healthcare Commercial	$3,807.00
Rate for Payer: United Healthcare Managed Medicare	$2,495.70

ACETABULAR SHELL SYSTEM-50E

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046815
Hospital Revenue Code	278
Min. Negotiated Rate	$1,961.10
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Aetna of IA Medicare	$2,484.06
Rate for Payer: Amerigroup Medicaid	$2,513.69
Rate for Payer: Amerigroup Medicare	$1,980.71
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,961.10
Rate for Payer: Iowa Total Care Managed Medicaid	$2,489.29
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Medical Associates Managed Medicare	$1,961.10
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,525.90
Rate for Payer: Partners Health Alliance Commercial	$2,255.26
Rate for Payer: United Healthcare Commercial	$3,922.20
Rate for Payer: United Healthcare Managed Medicare	$2,571.22

ACETABULAR SHELL SYSTEM-50E

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046815
Hospital Revenue Code	278
Min. Negotiated Rate	$3,050.60
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: United Healthcare Commercial	$3,922.20

ACETABULAR SHELL SYSTEM-52E

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046816
Hospital Revenue Code	278
Min. Negotiated Rate	$1,961.10
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Aetna of IA Medicare	$2,484.06
Rate for Payer: Amerigroup Medicaid	$2,513.69
Rate for Payer: Amerigroup Medicare	$1,980.71
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,961.10
Rate for Payer: Iowa Total Care Managed Medicaid	$2,489.29
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Medical Associates Managed Medicare	$1,961.10
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,525.90
Rate for Payer: Partners Health Alliance Commercial	$2,255.26
Rate for Payer: United Healthcare Commercial	$3,922.20
Rate for Payer: United Healthcare Managed Medicare	$2,571.22

ACETABULAR SHELL SYSTEM-52E

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046816
Hospital Revenue Code	278
Min. Negotiated Rate	$3,050.60
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: United Healthcare Commercial	$3,922.20

ACETABULAR SHELL SYSTEM-56F

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046818
Hospital Revenue Code	278
Min. Negotiated Rate	$1,961.10
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Aetna of IA Medicare	$2,484.06
Rate for Payer: Amerigroup Medicaid	$2,513.69
Rate for Payer: Amerigroup Medicare	$1,980.71
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,961.10
Rate for Payer: Iowa Total Care Managed Medicaid	$2,489.29
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Medical Associates Managed Medicare	$1,961.10
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,525.90
Rate for Payer: Partners Health Alliance Commercial	$2,255.26
Rate for Payer: United Healthcare Commercial	$3,922.20
Rate for Payer: United Healthcare Managed Medicare	$2,571.22

Know your out-of-pocket cost for care.

All Charges