|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
IP
|
$1,406.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
7855103
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$984.20 |
| Max. Negotiated Rate |
$1,265.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,265.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,265.40
|
| Rate for Payer: Cash Price |
$1,124.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,054.50
|
| Rate for Payer: Medical Associates Commercial |
$1,054.50
|
| Rate for Payer: Midlands Choice Commercial |
$984.20
|
| Rate for Payer: United Healthcare Commercial |
$1,265.40
|
|
|
DEB MUSC/FASCIA 20 SQ CM/<
|
Facility
|
OP
|
$1,406.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
7855103
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$632.70 |
| Max. Negotiated Rate |
$1,265.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,265.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,265.40
|
| Rate for Payer: Aetna of IA Medicare |
$801.42
|
| Rate for Payer: Amerigroup Medicaid |
$810.98
|
| Rate for Payer: Amerigroup Medicare |
$639.03
|
| Rate for Payer: Cash Price |
$1,124.80
|
| Rate for Payer: Cash Price |
$1,124.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,054.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$632.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$803.11
|
| Rate for Payer: Medical Associates Commercial |
$1,054.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$632.70
|
| Rate for Payer: Midlands Choice Commercial |
$984.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$814.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$727.60
|
| Rate for Payer: United Healthcare Commercial |
$1,265.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$829.54
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,023.80
|
| Rate for Payer: Wellmark IA PPO |
$1,127.76
|
|
|
DEB MUSC/FASCIA ADD-ON
|
Facility
|
IP
|
$662.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
7855104
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$463.40 |
| Max. Negotiated Rate |
$595.80 |
| Rate for Payer: Aetna of IA Commercial |
$595.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$595.80
|
| Rate for Payer: Cash Price |
$529.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$496.50
|
| Rate for Payer: Medical Associates Commercial |
$496.50
|
| Rate for Payer: Midlands Choice Commercial |
$463.40
|
| Rate for Payer: United Healthcare Commercial |
$595.80
|
|
|
DEB MUSC/FASCIA ADD-ON
|
Facility
|
OP
|
$662.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
7855104
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$297.90 |
| Max. Negotiated Rate |
$4,090.88 |
| Rate for Payer: Aetna of IA Commercial |
$595.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$595.80
|
| Rate for Payer: Aetna of IA Medicare |
$377.34
|
| Rate for Payer: Amerigroup Medicaid |
$381.84
|
| Rate for Payer: Amerigroup Medicare |
$300.88
|
| Rate for Payer: Cash Price |
$529.60
|
| Rate for Payer: Cash Price |
$529.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$496.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$297.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$378.13
|
| Rate for Payer: Medical Associates Commercial |
$496.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$297.90
|
| Rate for Payer: Midlands Choice Commercial |
$463.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$383.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$342.58
|
| Rate for Payer: United Healthcare Commercial |
$595.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$390.58
|
| Rate for Payer: Wellmark IA HMO WHPI |
$3,713.74
|
| Rate for Payer: Wellmark IA PPO |
$4,090.88
|
|
|
DEBRIDE GENITALIA PERINEUM
|
Facility
|
OP
|
$1,164.00
|
|
|
Service Code
|
CPT 11004
|
| Hospital Charge Code |
7982999
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$523.80 |
| Max. Negotiated Rate |
$4,090.88 |
| Rate for Payer: Aetna of IA Commercial |
$1,047.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,047.60
|
| Rate for Payer: Aetna of IA Medicare |
$663.48
|
| Rate for Payer: Amerigroup Medicaid |
$671.40
|
| Rate for Payer: Amerigroup Medicare |
$529.04
|
| Rate for Payer: Cash Price |
$931.20
|
| Rate for Payer: Cash Price |
$931.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$873.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$523.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$664.88
|
| Rate for Payer: Medical Associates Commercial |
$873.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$523.80
|
| Rate for Payer: Midlands Choice Commercial |
$814.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$674.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$602.37
|
| Rate for Payer: United Healthcare Commercial |
$1,047.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$686.76
|
| Rate for Payer: Wellmark IA HMO WHPI |
$3,713.74
|
| Rate for Payer: Wellmark IA PPO |
$4,090.88
|
|
|
DEBRIDE GENITALIA PERINEUM
|
Facility
|
IP
|
$1,164.00
|
|
|
Service Code
|
CPT 11004
|
| Hospital Charge Code |
7982999
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$814.80 |
| Max. Negotiated Rate |
$1,047.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,047.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,047.60
|
| Rate for Payer: Cash Price |
$931.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$873.00
|
| Rate for Payer: Medical Associates Commercial |
$873.00
|
| Rate for Payer: Midlands Choice Commercial |
$814.80
|
| Rate for Payer: United Healthcare Commercial |
$1,047.60
|
|
|
DEBRIDE INFECTED SKIN
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
CPT 11000
|
| Hospital Charge Code |
4862804
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$123.75 |
| Max. Negotiated Rate |
$1,127.76 |
| Rate for Payer: Aetna of IA Commercial |
$247.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$247.50
|
| Rate for Payer: Aetna of IA Medicare |
$156.75
|
| Rate for Payer: Amerigroup Medicaid |
$158.62
|
| Rate for Payer: Amerigroup Medicare |
$124.99
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$206.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$123.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$157.08
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$123.75
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$159.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$142.31
|
| Rate for Payer: United Healthcare Commercial |
$247.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$162.25
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,023.80
|
| Rate for Payer: Wellmark IA PPO |
$1,127.76
|
|
|
DEBRIDE INFECTED SKIN
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
CPT 11000
|
| Hospital Charge Code |
4862804
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$192.50 |
| Max. Negotiated Rate |
$247.50 |
| Rate for Payer: Aetna of IA Commercial |
$247.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$247.50
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$206.25
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: United Healthcare Commercial |
$247.50
|
|
|
DEBRIDEMENT IN ER CHARGE
|
Professional
|
Both
|
$204.00
|
|
| Hospital Charge Code |
8069137
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Medical Associates Commercial |
$153.00
|
| Rate for Payer: Midlands Choice Commercial |
$142.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$153.00
|
|
|
DEBRIDE NAIL 1-5
|
Professional
|
Both
|
$106.00
|
|
|
Service Code
|
CPT 11720
|
| Hospital Charge Code |
7982850
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$24.38 |
| Max. Negotiated Rate |
$79.50 |
| Rate for Payer: Amerigroup Medicaid |
$24.62
|
| Rate for Payer: Cash Price |
$84.80
|
| Rate for Payer: Cash Price |
$84.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.38
|
| Rate for Payer: Medical Associates Commercial |
$79.50
|
| Rate for Payer: Midlands Choice Commercial |
$74.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$79.50
|
| Rate for Payer: United Healthcare Commercial |
$49.58
|
| Rate for Payer: Wellmark IA HMO WHPI |
$60.20
|
| Rate for Payer: Wellmark IA PPO |
$70.80
|
|
|
DEBRIDE NAIL 1-5
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
CPT 11720
|
| Hospital Charge Code |
4863310
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$50.85 |
| Max. Negotiated Rate |
$487.34 |
| Rate for Payer: Aetna of IA Commercial |
$101.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$101.70
|
| Rate for Payer: Aetna of IA Medicare |
$64.41
|
| Rate for Payer: Amerigroup Medicaid |
$65.18
|
| Rate for Payer: Amerigroup Medicare |
$51.36
|
| Rate for Payer: Cash Price |
$90.40
|
| Rate for Payer: Cash Price |
$90.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$50.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$64.55
|
| Rate for Payer: Medical Associates Commercial |
$84.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$50.85
|
| Rate for Payer: Midlands Choice Commercial |
$79.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$65.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$58.48
|
| Rate for Payer: United Healthcare Commercial |
$101.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$66.67
|
| Rate for Payer: Wellmark IA HMO WHPI |
$442.42
|
| Rate for Payer: Wellmark IA PPO |
$487.34
|
|
|
DEBRIDE NAIL 1-5
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
CPT 11720
|
| Hospital Charge Code |
4863310
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$79.10 |
| Max. Negotiated Rate |
$101.70 |
| Rate for Payer: Aetna of IA Commercial |
$101.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$101.70
|
| Rate for Payer: Cash Price |
$90.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.75
|
| Rate for Payer: Medical Associates Commercial |
$84.75
|
| Rate for Payer: Midlands Choice Commercial |
$79.10
|
| Rate for Payer: United Healthcare Commercial |
$101.70
|
|
|
DEBRIDE SKIN AT FX SITE
|
Facility
|
OP
|
$1,696.00
|
|
|
Service Code
|
CPT 11010
|
| Hospital Charge Code |
4862806
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$763.20 |
| Max. Negotiated Rate |
$1,526.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,526.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,526.40
|
| Rate for Payer: Aetna of IA Medicare |
$966.72
|
| Rate for Payer: Amerigroup Medicaid |
$978.25
|
| Rate for Payer: Amerigroup Medicare |
$770.83
|
| Rate for Payer: Cash Price |
$1,356.80
|
| Rate for Payer: Cash Price |
$1,356.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,272.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$763.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$968.76
|
| Rate for Payer: Medical Associates Commercial |
$1,272.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$763.20
|
| Rate for Payer: Midlands Choice Commercial |
$1,187.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$983.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$877.68
|
| Rate for Payer: United Healthcare Commercial |
$1,526.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,000.64
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,023.80
|
| Rate for Payer: Wellmark IA PPO |
$1,127.76
|
|
|
DEBRIDE SKIN AT FX SITE
|
Facility
|
IP
|
$1,696.00
|
|
|
Service Code
|
CPT 11010
|
| Hospital Charge Code |
4862806
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,187.20 |
| Max. Negotiated Rate |
$1,526.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,526.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,526.40
|
| Rate for Payer: Cash Price |
$1,356.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,272.00
|
| Rate for Payer: Medical Associates Commercial |
$1,272.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,187.20
|
| Rate for Payer: United Healthcare Commercial |
$1,526.40
|
|
|
DEB SUBQ TISSUE 20 SQ CM/<
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
4862809
|
|
Hospital Revenue Code
|
450
|
| 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
|
|
|
DEB SUBQ TISSUE 20 SQ CM/<
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
4862809
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$154.80 |
| Max. Negotiated Rate |
$1,127.76 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,023.80
|
| Rate for Payer: Wellmark IA PPO |
$1,127.76
|
|
|
DEB SUBQ TISSUE 20 SQ CM/<
|
Professional
|
Both
|
$385.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
7982853
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$67.76 |
| Max. Negotiated Rate |
$288.75 |
| Rate for Payer: Amerigroup Medicaid |
$68.42
|
| Rate for Payer: Cash Price |
$308.00
|
| Rate for Payer: Cash Price |
$308.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.76
|
| Rate for Payer: Medical Associates Commercial |
$288.75
|
| Rate for Payer: Midlands Choice Commercial |
$269.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$288.75
|
| Rate for Payer: United Healthcare Commercial |
$189.06
|
| Rate for Payer: Wellmark IA HMO WHPI |
$237.00
|
| Rate for Payer: Wellmark IA PPO |
$278.80
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
7855102
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$154.80 |
| Max. Negotiated Rate |
$4,090.88 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$3,713.74
|
| Rate for Payer: Wellmark IA PPO |
$4,090.88
|
|
|
DEB SUBQ TISSUE ADD-ON
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
7855102
|
|
Hospital Revenue Code
|
450
|
| 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
|
|
|
DECELLULARIZED DERMIS 50X90
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
8785363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$101.70 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of IA Commercial |
$203.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$203.40
|
| Rate for Payer: Aetna of IA Medicare |
$128.82
|
| Rate for Payer: Amerigroup Medicaid |
$130.36
|
| Rate for Payer: Amerigroup Medicare |
$102.72
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$169.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$101.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$129.09
|
| Rate for Payer: Medical Associates Commercial |
$169.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$101.70
|
| Rate for Payer: Midlands Choice Commercial |
$158.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$130.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$116.96
|
| Rate for Payer: United Healthcare Commercial |
$203.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$133.34
|
|
|
DECELLULARIZED DERMIS 50X90
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
HCPCS Q4125
|
| Hospital Charge Code |
8785363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.20 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of IA Commercial |
$203.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$203.40
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$169.50
|
| Rate for Payer: Medical Associates Commercial |
$169.50
|
| Rate for Payer: Midlands Choice Commercial |
$158.20
|
| Rate for Payer: United Healthcare Commercial |
$203.40
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
8398095
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$150.30 |
| Rate for Payer: Aetna of IA Commercial |
$150.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$150.30
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$125.25
|
| Rate for Payer: Medical Associates Commercial |
$125.25
|
| Rate for Payer: Midlands Choice Commercial |
$116.90
|
| Rate for Payer: United Healthcare Commercial |
$150.30
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
8398095
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$75.15 |
| Max. Negotiated Rate |
$598.25 |
| Rate for Payer: Aetna of IA Commercial |
$150.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$150.30
|
| Rate for Payer: Aetna of IA Medicare |
$95.19
|
| Rate for Payer: Amerigroup Medicaid |
$96.33
|
| Rate for Payer: Amerigroup Medicare |
$75.90
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$125.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$95.39
|
| Rate for Payer: Medical Associates Commercial |
$125.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.15
|
| Rate for Payer: Midlands Choice Commercial |
$116.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$96.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$86.42
|
| Rate for Payer: United Healthcare Commercial |
$150.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$98.53
|
| Rate for Payer: Wellmark IA HMO WHPI |
$543.09
|
| Rate for Payer: Wellmark IA PPO |
$598.25
|
|
|
DECOMPRESSION OF LEG
|
Facility
|
IP
|
$3,796.00
|
|
|
Service Code
|
CPT 27893
|
| Hospital Charge Code |
7982998
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,657.20 |
| Max. Negotiated Rate |
$3,416.40 |
| Rate for Payer: Aetna of IA Commercial |
$3,416.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,416.40
|
| Rate for Payer: Cash Price |
$3,036.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,847.00
|
| Rate for Payer: Medical Associates Commercial |
$2,847.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,657.20
|
| Rate for Payer: United Healthcare Commercial |
$3,416.40
|
|
|
DECOMPRESSION OF LEG
|
Facility
|
OP
|
$3,796.00
|
|
|
Service Code
|
CPT 27893
|
| Hospital Charge Code |
7982998
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,708.20 |
| Max. Negotiated Rate |
$7,923.25 |
| Rate for Payer: Aetna of IA Commercial |
$3,416.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,416.40
|
| Rate for Payer: Aetna of IA Medicare |
$2,163.72
|
| Rate for Payer: Amerigroup Medicaid |
$2,189.53
|
| Rate for Payer: Amerigroup Medicare |
$1,725.28
|
| Rate for Payer: Cash Price |
$3,036.80
|
| Rate for Payer: Cash Price |
$3,036.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,847.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,708.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,168.28
|
| Rate for Payer: Medical Associates Commercial |
$2,847.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,708.20
|
| Rate for Payer: Midlands Choice Commercial |
$2,657.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,200.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,964.43
|
| Rate for Payer: United Healthcare Commercial |
$3,416.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,239.64
|
| Rate for Payer: Wellmark IA HMO WHPI |
$7,192.81
|
| Rate for Payer: Wellmark IA PPO |
$7,923.25
|
|
