Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

SCREW CANCELLOUS 4.0MMX14MM BONE FULLY T

Facility

$40.00

Service Code	HCPCS C1713
Hospital Charge Code	8046886
Hospital Revenue Code	278
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of IA Commercial	$36.00
Rate for Payer: Aetna of IA Medical Rental Products	$36.00
Rate for Payer: Aetna of IA Medicare	$22.80
Rate for Payer: Amerigroup Medicaid	$23.07
Rate for Payer: Amerigroup Medicare	$18.18
Rate for Payer: Cash Price	$32.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.00
Rate for Payer: Iowa Total Care Managed Medicaid	$22.85
Rate for Payer: Medical Associates Commercial	$30.00
Rate for Payer: Medical Associates Managed Medicare	$18.00
Rate for Payer: Midlands Choice Commercial	$28.00
Rate for Payer: Molina Healthcare Managed Medicaid	$23.18
Rate for Payer: Partners Health Alliance Commercial	$20.70
Rate for Payer: United Healthcare Commercial	$36.00
Rate for Payer: United Healthcare Managed Medicare	$23.60

SCREW CANCELLOUS 4.0MMX14MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046812
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX14MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046812
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX16MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8047022
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX16MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8047022
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX16MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8047007
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX16MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8047007
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX18MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046703
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX18MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046703
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX18MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8047028
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX18MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8047028
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX20MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046402
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX20MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046402
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX20MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046900
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX20MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046900
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX22MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046974
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX22MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046974
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX22MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8047003
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX22MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8047003
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX24MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046727
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX24MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046727
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX24MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046373
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

SCREW CANCELLOUS 4.0MMX24MM PARTIAL THRE

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046373
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX26MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046728
Hospital Revenue Code	278
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Aetna of IA Medicare	$19.95
Rate for Payer: Amerigroup Medicaid	$20.19
Rate for Payer: Amerigroup Medicare	$15.91
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.75
Rate for Payer: Iowa Total Care Managed Medicaid	$19.99
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Medical Associates Managed Medicare	$15.75
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: Molina Healthcare Managed Medicaid	$20.29
Rate for Payer: Partners Health Alliance Commercial	$18.11
Rate for Payer: United Healthcare Commercial	$31.50
Rate for Payer: United Healthcare Managed Medicare	$20.65

SCREW CANCELLOUS 4.0MMX26MM BONE FULLY T

Facility

$35.00

Service Code	HCPCS C1713
Hospital Charge Code	8046728
Hospital Revenue Code	278
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of IA Commercial	$31.50
Rate for Payer: Aetna of IA Medical Rental Products	$31.50
Rate for Payer: Cash Price	$28.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.25
Rate for Payer: Medical Associates Commercial	$26.25
Rate for Payer: Midlands Choice Commercial	$24.50
Rate for Payer: United Healthcare Commercial	$31.50

Know your out-of-pocket cost for care.

All Charges