Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

SCREW LOCKING AXSOS 4.0XL18MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046681
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL20MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046682
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL20MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046682
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL22MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046683
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL22MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046683
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL24MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046684
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL24MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046684
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL26MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046685
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL26MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046685
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL28MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046686
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL28MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046686
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL30MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046687
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL30MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046687
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL32MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046688
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL32MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046688
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL34MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046689
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL34MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046689
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL36MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046690
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL36MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046690
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL38MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046691
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL38MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046691
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL40MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046692
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

SCREW LOCKING AXSOS 4.0XL40MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046692
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL42MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046693
Hospital Revenue Code	278
Min. Negotiated Rate	$67.05
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Aetna of IA Medicare	$84.93
Rate for Payer: Amerigroup Medicaid	$85.94
Rate for Payer: Amerigroup Medicare	$67.72
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.05
Rate for Payer: Iowa Total Care Managed Medicaid	$85.11
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Medical Associates Managed Medicare	$67.05
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: Molina Healthcare Managed Medicaid	$86.36
Rate for Payer: Partners Health Alliance Commercial	$77.11
Rate for Payer: United Healthcare Commercial	$134.10
Rate for Payer: United Healthcare Managed Medicare	$87.91

SCREW LOCKING AXSOS 4.0XL42MM

Facility

$149.00

Service Code	HCPCS C1713
Hospital Charge Code	8046693
Hospital Revenue Code	278
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of IA Commercial	$134.10
Rate for Payer: Aetna of IA Medical Rental Products	$134.10
Rate for Payer: Cash Price	$119.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.75
Rate for Payer: Medical Associates Commercial	$111.75
Rate for Payer: Midlands Choice Commercial	$104.30
Rate for Payer: United Healthcare Commercial	$134.10

Know your out-of-pocket cost for care.

All Charges