Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LOCKING THIRD TUBULAR, SS, 5H

Facility

$317.00

Service Code	HCPCS C1713
Hospital Charge Code	8047170
Hospital Revenue Code	278
Min. Negotiated Rate	$221.90
Max. Negotiated Rate	$285.30
Rate for Payer: Aetna of IA Commercial	$285.30
Rate for Payer: Aetna of IA Medical Rental Products	$285.30
Rate for Payer: Cash Price	$253.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$237.75
Rate for Payer: Medical Associates Commercial	$237.75
Rate for Payer: Midlands Choice Commercial	$221.90
Rate for Payer: United Healthcare Commercial	$285.30

PLATE LOCKING THIRD TUBULAR, SS, 6H

Facility

$324.00

Service Code	HCPCS C1713
Hospital Charge Code	8047171
Hospital Revenue Code	278
Min. Negotiated Rate	$145.80
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Aetna of IA Medicare	$184.68
Rate for Payer: Amerigroup Medicaid	$186.88
Rate for Payer: Amerigroup Medicare	$147.26
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$145.80
Rate for Payer: Iowa Total Care Managed Medicaid	$185.07
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Medical Associates Managed Medicare	$145.80
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: Molina Healthcare Managed Medicaid	$187.79
Rate for Payer: Partners Health Alliance Commercial	$167.67
Rate for Payer: United Healthcare Commercial	$291.60
Rate for Payer: United Healthcare Managed Medicare	$191.16

PLATE LOCKING THIRD TUBULAR, SS, 6H

Facility

$324.00

Service Code	HCPCS C1713
Hospital Charge Code	8047171
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: United Healthcare Commercial	$291.60

PLATE LOCKING THIRD TUBULAR, SS, 7H

Facility

$344.00

Service Code	HCPCS C1713
Hospital Charge Code	8047172
Hospital Revenue Code	278
Min. Negotiated Rate	$240.80
Max. Negotiated Rate	$309.60
Rate for Payer: Aetna of IA Commercial	$309.60
Rate for Payer: Aetna of IA Medical Rental Products	$309.60
Rate for Payer: Cash Price	$275.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$258.00
Rate for Payer: Medical Associates Commercial	$258.00
Rate for Payer: Midlands Choice Commercial	$240.80
Rate for Payer: United Healthcare Commercial	$309.60

PLATE LOCKING THIRD TUBULAR, SS, 7H

Facility

$344.00

Service Code	HCPCS C1713
Hospital Charge Code	8047172
Hospital Revenue Code	278
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$309.60
Rate for Payer: Aetna of IA Commercial	$309.60
Rate for Payer: Aetna of IA Medical Rental Products	$309.60
Rate for Payer: Aetna of IA Medicare	$196.08
Rate for Payer: Amerigroup Medicaid	$198.42
Rate for Payer: Amerigroup Medicare	$156.35
Rate for Payer: Cash Price	$275.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$258.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$154.80
Rate for Payer: Iowa Total Care Managed Medicaid	$196.49
Rate for Payer: Medical Associates Commercial	$258.00
Rate for Payer: Medical Associates Managed Medicare	$154.80
Rate for Payer: Midlands Choice Commercial	$240.80
Rate for Payer: Molina Healthcare Managed Medicaid	$199.38
Rate for Payer: Partners Health Alliance Commercial	$178.02
Rate for Payer: United Healthcare Commercial	$309.60
Rate for Payer: United Healthcare Managed Medicare	$202.96

PLATE LOCKING THIRD TUBULAR, SS, 8H

Facility

$477.00

Service Code	HCPCS C1713
Hospital Charge Code	8047173
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 THIRD TUBULAR, SS, 8H

Facility

$477.00

Service Code	HCPCS C1713
Hospital Charge Code	8047173
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 PROXIMAL LATERAL HUMERUS 3 LEFT

Facility

$1,578.00

Service Code	HCPCS C1713
Hospital Charge Code	8046781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,104.60
Max. Negotiated Rate	$1,420.20
Rate for Payer: Aetna of IA Commercial	$1,420.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,420.20
Rate for Payer: Cash Price	$1,262.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,183.50
Rate for Payer: Medical Associates Commercial	$1,183.50
Rate for Payer: Midlands Choice Commercial	$1,104.60
Rate for Payer: United Healthcare Commercial	$1,420.20

PLATE PROXIMAL LATERAL HUMERUS 3 LEFT

Facility

$1,578.00

Service Code	HCPCS C1713
Hospital Charge Code	8046781
Hospital Revenue Code	278
Min. Negotiated Rate	$710.10
Max. Negotiated Rate	$1,420.20
Rate for Payer: Aetna of IA Commercial	$1,420.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,420.20
Rate for Payer: Aetna of IA Medicare	$899.46
Rate for Payer: Amerigroup Medicaid	$910.19
Rate for Payer: Amerigroup Medicare	$717.20
Rate for Payer: Cash Price	$1,262.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,183.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$710.10
Rate for Payer: Iowa Total Care Managed Medicaid	$901.35
Rate for Payer: Medical Associates Commercial	$1,183.50
Rate for Payer: Medical Associates Managed Medicare	$710.10
Rate for Payer: Midlands Choice Commercial	$1,104.60
Rate for Payer: Molina Healthcare Managed Medicaid	$914.61
Rate for Payer: Partners Health Alliance Commercial	$816.62
Rate for Payer: United Healthcare Commercial	$1,420.20
Rate for Payer: United Healthcare Managed Medicare	$931.02

PLATE PROXIMAL LATERAL HUMERUS 3 RIGHT

Facility

$1,578.00

Service Code	HCPCS C1713
Hospital Charge Code	8046782
Hospital Revenue Code	278
Min. Negotiated Rate	$710.10
Max. Negotiated Rate	$1,420.20
Rate for Payer: Aetna of IA Commercial	$1,420.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,420.20
Rate for Payer: Aetna of IA Medicare	$899.46
Rate for Payer: Amerigroup Medicaid	$910.19
Rate for Payer: Amerigroup Medicare	$717.20
Rate for Payer: Cash Price	$1,262.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,183.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$710.10
Rate for Payer: Iowa Total Care Managed Medicaid	$901.35
Rate for Payer: Medical Associates Commercial	$1,183.50
Rate for Payer: Medical Associates Managed Medicare	$710.10
Rate for Payer: Midlands Choice Commercial	$1,104.60
Rate for Payer: Molina Healthcare Managed Medicaid	$914.61
Rate for Payer: Partners Health Alliance Commercial	$816.62
Rate for Payer: United Healthcare Commercial	$1,420.20
Rate for Payer: United Healthcare Managed Medicare	$931.02

PLATE PROXIMAL LATERAL HUMERUS 3 RIGHT

Facility

$1,578.00

Service Code	HCPCS C1713
Hospital Charge Code	8046782
Hospital Revenue Code	278
Min. Negotiated Rate	$1,104.60
Max. Negotiated Rate	$1,420.20
Rate for Payer: Aetna of IA Commercial	$1,420.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,420.20
Rate for Payer: Cash Price	$1,262.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,183.50
Rate for Payer: Medical Associates Commercial	$1,183.50
Rate for Payer: Midlands Choice Commercial	$1,104.60
Rate for Payer: United Healthcare Commercial	$1,420.20

PLATE SMARTLOCK VOLAR NARROW RIGHT

Facility

$1,300.00

Service Code	HCPCS C1713
Hospital Charge Code	8046814
Hospital Revenue Code	278
Min. Negotiated Rate	$585.00
Max. Negotiated Rate	$1,170.00
Rate for Payer: Aetna of IA Commercial	$1,170.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,170.00
Rate for Payer: Aetna of IA Medicare	$741.00
Rate for Payer: Amerigroup Medicaid	$749.84
Rate for Payer: Amerigroup Medicare	$590.85
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$975.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$585.00
Rate for Payer: Iowa Total Care Managed Medicaid	$742.56
Rate for Payer: Medical Associates Commercial	$975.00
Rate for Payer: Medical Associates Managed Medicare	$585.00
Rate for Payer: Midlands Choice Commercial	$910.00
Rate for Payer: Molina Healthcare Managed Medicaid	$753.48
Rate for Payer: Partners Health Alliance Commercial	$672.75
Rate for Payer: United Healthcare Commercial	$1,170.00
Rate for Payer: United Healthcare Managed Medicare	$767.00

PLATE SMARTLOCK VOLAR NARROW RIGHT

Facility

$1,300.00

Service Code	HCPCS C1713
Hospital Charge Code	8046814
Hospital Revenue Code	278
Min. Negotiated Rate	$910.00
Max. Negotiated Rate	$1,170.00
Rate for Payer: Aetna of IA Commercial	$1,170.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,170.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$975.00
Rate for Payer: Medical Associates Commercial	$975.00
Rate for Payer: Midlands Choice Commercial	$910.00
Rate for Payer: United Healthcare Commercial	$1,170.00

PLATES TUBULAR SPS 1/3 410 HOLE L129

Facility

$71.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046774
Hospital Revenue Code	278
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89

PLATES TUBULAR SPS 1/3 410 HOLE L129

Facility

$71.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046774
Hospital Revenue Code	278
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

PLATES TUBULAR SPS 1/3 4 HOLE L51

Facility

$64.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046770
Hospital Revenue Code	278
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

PLATES TUBULAR SPS 1/3 4 HOLE L51

Facility

$64.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046770
Hospital Revenue Code	278
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76

PLATES TUBULAR SPS 1/3 5 HOLE L64

Facility

$64.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046771
Hospital Revenue Code	278
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76

PLATES TUBULAR SPS 1/3 5 HOLE L64

Facility

$64.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046771
Hospital Revenue Code	278
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

PLATES TUBULAR SPS 1/3 6 HOLE L77

Facility

$93.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046772
Hospital Revenue Code	278
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of IA Commercial	$83.70
Rate for Payer: Aetna of IA Medical Rental Products	$83.70
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.75
Rate for Payer: Medical Associates Commercial	$69.75
Rate for Payer: Midlands Choice Commercial	$65.10
Rate for Payer: United Healthcare Commercial	$83.70

PLATES TUBULAR SPS 1/3 6 HOLE L77

Facility

$93.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046772
Hospital Revenue Code	278
Min. Negotiated Rate	$41.85
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of IA Commercial	$83.70
Rate for Payer: Aetna of IA Medical Rental Products	$83.70
Rate for Payer: Aetna of IA Medicare	$53.01
Rate for Payer: Amerigroup Medicaid	$53.64
Rate for Payer: Amerigroup Medicare	$42.27
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.85
Rate for Payer: Iowa Total Care Managed Medicaid	$53.12
Rate for Payer: Medical Associates Commercial	$69.75
Rate for Payer: Medical Associates Managed Medicare	$41.85
Rate for Payer: Midlands Choice Commercial	$65.10
Rate for Payer: Molina Healthcare Managed Medicaid	$53.90
Rate for Payer: Partners Health Alliance Commercial	$48.13
Rate for Payer: United Healthcare Commercial	$83.70
Rate for Payer: United Healthcare Managed Medicare	$54.87

PLATES TUBULAR SPS 1/3 8 HOLE L103

Facility

$104.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046773
Hospital Revenue Code	278
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of IA Commercial	$93.60
Rate for Payer: Aetna of IA Medical Rental Products	$93.60
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.00
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: United Healthcare Commercial	$93.60

PLATES TUBULAR SPS 1/3 8 HOLE L103

Facility

$104.00

Service Code	HCPCS Q4107
Hospital Charge Code	8046773
Hospital Revenue Code	278
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of IA Commercial	$93.60
Rate for Payer: Aetna of IA Medical Rental Products	$93.60
Rate for Payer: Aetna of IA Medicare	$59.28
Rate for Payer: Amerigroup Medicaid	$59.99
Rate for Payer: Amerigroup Medicare	$47.27
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$46.80
Rate for Payer: Iowa Total Care Managed Medicaid	$59.40
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Medical Associates Managed Medicare	$46.80
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: Molina Healthcare Managed Medicaid	$60.28
Rate for Payer: Partners Health Alliance Commercial	$53.82
Rate for Payer: United Healthcare Commercial	$93.60
Rate for Payer: United Healthcare Managed Medicare	$61.36

PLATE TUBULAR LOCKING 10 HOLE L50MM

Facility

$175.00

Service Code	HCPCS C1713
Hospital Charge Code	8046742
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of IA Commercial	$157.50
Rate for Payer: Aetna of IA Medical Rental Products	$157.50
Rate for Payer: Aetna of IA Medicare	$99.75
Rate for Payer: Amerigroup Medicaid	$100.94
Rate for Payer: Amerigroup Medicare	$79.54
Rate for Payer: Cash Price	$140.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$131.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$78.75
Rate for Payer: Iowa Total Care Managed Medicaid	$99.96
Rate for Payer: Medical Associates Commercial	$131.25
Rate for Payer: Medical Associates Managed Medicare	$78.75
Rate for Payer: Midlands Choice Commercial	$122.50
Rate for Payer: Molina Healthcare Managed Medicaid	$101.43
Rate for Payer: Partners Health Alliance Commercial	$90.56
Rate for Payer: United Healthcare Commercial	$157.50
Rate for Payer: United Healthcare Managed Medicare	$103.25

PLATE TUBULAR LOCKING 10 HOLE L50MM

Facility

$175.00

Service Code	HCPCS C1713
Hospital Charge Code	8046742
Hospital Revenue Code	278
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of IA Commercial	$157.50
Rate for Payer: Aetna of IA Medical Rental Products	$157.50
Rate for Payer: Cash Price	$140.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$131.25
Rate for Payer: Medical Associates Commercial	$131.25
Rate for Payer: Midlands Choice Commercial	$122.50
Rate for Payer: United Healthcare Commercial	$157.50

Know your out-of-pocket cost for care.

All Charges