|
Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy With CC
|
Facility
|
IP
|
$13,195.72
|
|
|
Service Code
|
MS-DRG 543
|
| Hospital Charge Code |
350
|
| Min. Negotiated Rate |
$13,004.48 |
| Max. Negotiated Rate |
$13,195.72 |
| Rate for Payer: Amerigroup Medicaid |
$13,131.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13,004.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13,195.72
|
|
|
Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy With MCC
|
Facility
|
IP
|
$15,097.28
|
|
|
Service Code
|
MS-DRG 542
|
| Hospital Charge Code |
349
|
| Min. Negotiated Rate |
$14,878.47 |
| Max. Negotiated Rate |
$15,097.28 |
| Rate for Payer: Amerigroup Medicaid |
$15,024.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14,878.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15,097.28
|
|
|
Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy Without CC/MCC
|
Facility
|
IP
|
$4,692.87
|
|
|
Service Code
|
MS-DRG 544
|
| Hospital Charge Code |
351
|
| Min. Negotiated Rate |
$4,624.85 |
| Max. Negotiated Rate |
$4,692.87 |
| Rate for Payer: Amerigroup Medicaid |
$4,670.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,624.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,692.87
|
|
|
Pathology Gyn Request DMCL
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT G0123
|
| Hospital Charge Code |
8037736
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna of IA Commercial |
$99.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$82.50
|
| Rate for Payer: Medical Associates Commercial |
$82.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.00
|
| Rate for Payer: United Healthcare Commercial |
$99.00
|
|
|
Pathology Gyn Request DMCL
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT G0123
|
| Hospital Charge Code |
8037736
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna of IA Commercial |
$99.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.00
|
| Rate for Payer: Aetna of IA Medicare |
$62.70
|
| Rate for Payer: Amerigroup Medicaid |
$55.52
|
| Rate for Payer: Amerigroup Medicare |
$55.55
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$82.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$54.98
|
| Rate for Payer: Medical Associates Commercial |
$82.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.00
|
| Rate for Payer: Midlands Choice Commercial |
$77.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$55.82
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$55.79
|
| Rate for Payer: Oscar Health of IA Commercial |
$82.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$82.50
|
| Rate for Payer: United Healthcare Commercial |
$99.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.90
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
patiromer 16.8 g Pow [VDMC]
|
Facility
|
OP
|
$113.69
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
18292192
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.82 |
| Max. Negotiated Rate |
$102.32 |
| Rate for Payer: Aetna of IA Commercial |
$102.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.32
|
| Rate for Payer: Aetna of IA Medicare |
$64.80
|
| Rate for Payer: Amerigroup Medicaid |
$57.38
|
| Rate for Payer: Amerigroup Medicare |
$57.41
|
| Rate for Payer: Cash Price |
$90.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.27
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$56.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.82
|
| Rate for Payer: Medical Associates Commercial |
$85.27
|
| Rate for Payer: Medical Associates Managed Medicare |
$56.84
|
| Rate for Payer: Midlands Choice Commercial |
$79.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.70
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$57.66
|
| Rate for Payer: Oscar Health of IA Commercial |
$85.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.27
|
| Rate for Payer: United Healthcare Commercial |
$102.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.08
|
|
|
patiromer 16.8 g Pow [VDMC]
|
Facility
|
IP
|
$113.69
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
18292192
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$79.58 |
| Max. Negotiated Rate |
$102.32 |
| Rate for Payer: Aetna of IA Commercial |
$102.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.32
|
| Rate for Payer: Cash Price |
$90.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.27
|
| Rate for Payer: Medical Associates Commercial |
$85.27
|
| Rate for Payer: Midlands Choice Commercial |
$79.58
|
| Rate for Payer: United Healthcare Commercial |
$102.32
|
|
|
Peds Med Surg
|
Facility
|
IP
|
$1,300.00
|
|
| Hospital Charge Code |
8002759
|
|
Hospital Revenue Code
|
113
|
| Min. Negotiated Rate |
$910.00 |
| Max. Negotiated Rate |
$9,842.42 |
| 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 |
$2,258.00
|
| Rate for Payer: Amerigroup Medicare |
$2,054.34
|
| Rate for Payer: Cash Price |
$1,040.00
|
| Rate for Payer: Cash Price |
$1,040.00
|
| 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 |
$2,034.00
|
| Rate for Payer: Medical Associates Commercial |
$975.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,034.00
|
| Rate for Payer: Midlands Choice Commercial |
$910.00
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$9,842.42
|
| Rate for Payer: Oscar Health of IA Commercial |
$3,051.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,339.10
|
| Rate for Payer: United Healthcare Commercial |
$1,170.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,306.00
|
|
|
peg 3350 electrolytes100-7.5-2.691gm Oral Pwdr for Sol [VDMC]
|
Facility
|
OP
|
$214.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10412200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$107.08 |
| Max. Negotiated Rate |
$192.82 |
| Rate for Payer: Aetna of IA Commercial |
$192.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$192.82
|
| Rate for Payer: Aetna of IA Medicare |
$122.12
|
| Rate for Payer: Amerigroup Medicaid |
$108.13
|
| Rate for Payer: Amerigroup Medicare |
$108.19
|
| Rate for Payer: Cash Price |
$171.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$160.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$107.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$107.08
|
| Rate for Payer: Medical Associates Commercial |
$160.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$107.12
|
| Rate for Payer: Midlands Choice Commercial |
$149.97
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$108.73
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$108.66
|
| Rate for Payer: Oscar Health of IA Commercial |
$160.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$160.68
|
| Rate for Payer: United Healthcare Commercial |
$192.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$126.40
|
|
|
peg 3350 electrolytes100-7.5-2.691gm Oral Pwdr for Sol [VDMC]
|
Facility
|
IP
|
$214.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10412200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$149.97 |
| Max. Negotiated Rate |
$192.82 |
| Rate for Payer: Aetna of IA Commercial |
$192.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$192.82
|
| Rate for Payer: Cash Price |
$171.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$160.68
|
| Rate for Payer: Medical Associates Commercial |
$160.68
|
| Rate for Payer: Midlands Choice Commercial |
$149.97
|
| Rate for Payer: United Healthcare Commercial |
$192.82
|
|
|
PEG 3350 electrolytes Oral Pwdr for Sol 4000 mL [VDMC]
|
Facility
|
IP
|
$98.68
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414263
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$69.08 |
| Max. Negotiated Rate |
$88.81 |
| Rate for Payer: Aetna of IA Commercial |
$88.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.81
|
| Rate for Payer: Cash Price |
$78.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.01
|
| Rate for Payer: Medical Associates Commercial |
$74.01
|
| Rate for Payer: Midlands Choice Commercial |
$69.08
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
|
|
PEG 3350 electrolytes Oral Pwdr for Sol 4000 mL [VDMC]
|
Facility
|
OP
|
$98.68
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414263
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.32 |
| Max. Negotiated Rate |
$88.81 |
| Rate for Payer: Aetna of IA Commercial |
$88.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.81
|
| Rate for Payer: Aetna of IA Medicare |
$56.25
|
| Rate for Payer: Amerigroup Medicaid |
$49.80
|
| Rate for Payer: Amerigroup Medicare |
$49.83
|
| Rate for Payer: Cash Price |
$78.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$49.32
|
| Rate for Payer: Medical Associates Commercial |
$74.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.34
|
| Rate for Payer: Midlands Choice Commercial |
$69.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$50.08
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$50.05
|
| Rate for Payer: Oscar Health of IA Commercial |
$74.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$74.01
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$58.22
|
|
|
peg 400-propylene glycol drops [VDMC]
|
Facility
|
IP
|
$56.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10409939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.51 |
| Max. Negotiated Rate |
$50.80 |
| Rate for Payer: Aetna of IA Commercial |
$50.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.80
|
| Rate for Payer: Cash Price |
$45.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.33
|
| Rate for Payer: Medical Associates Commercial |
$42.33
|
| Rate for Payer: Midlands Choice Commercial |
$39.51
|
| Rate for Payer: United Healthcare Commercial |
$50.80
|
|
|
peg 400-propylene glycol drops [VDMC]
|
Facility
|
OP
|
$56.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10409939
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.21 |
| Max. Negotiated Rate |
$50.80 |
| Rate for Payer: Aetna of IA Commercial |
$50.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.80
|
| Rate for Payer: Aetna of IA Medicare |
$32.17
|
| Rate for Payer: Amerigroup Medicaid |
$28.49
|
| Rate for Payer: Amerigroup Medicare |
$28.50
|
| Rate for Payer: Cash Price |
$45.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.21
|
| Rate for Payer: Medical Associates Commercial |
$42.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.22
|
| Rate for Payer: Midlands Choice Commercial |
$39.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$28.64
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$28.63
|
| Rate for Payer: Oscar Health of IA Commercial |
$42.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.33
|
| Rate for Payer: United Healthcare Commercial |
$50.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.30
|
|
|
pegfilgrastim 6 mg/0.6 mL SubQ SDV Inj [VDMC]
|
Facility
|
IP
|
$8,145.98
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
10412131
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5,702.19 |
| Max. Negotiated Rate |
$7,331.38 |
| Rate for Payer: Aetna of IA Commercial |
$7,331.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,331.38
|
| Rate for Payer: Cash Price |
$6,516.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,109.48
|
| Rate for Payer: Medical Associates Commercial |
$6,109.48
|
| Rate for Payer: Midlands Choice Commercial |
$5,702.19
|
| Rate for Payer: United Healthcare Commercial |
$7,331.38
|
|
|
pegfilgrastim 6 mg/0.6 mL SubQ SDV Inj [VDMC]
|
Facility
|
OP
|
$8,145.98
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
10412131
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,071.36 |
| Max. Negotiated Rate |
$7,331.38 |
| Rate for Payer: Aetna of IA Commercial |
$7,331.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,331.38
|
| Rate for Payer: Aetna of IA Medicare |
$4,643.21
|
| Rate for Payer: Amerigroup Medicaid |
$4,111.28
|
| Rate for Payer: Amerigroup Medicare |
$4,113.72
|
| Rate for Payer: Cash Price |
$6,516.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,109.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,072.99
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,071.36
|
| Rate for Payer: Medical Associates Commercial |
$6,109.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,072.99
|
| Rate for Payer: Midlands Choice Commercial |
$5,702.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,134.08
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$4,131.64
|
| Rate for Payer: Oscar Health of IA Commercial |
$6,109.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,109.48
|
| Rate for Payer: United Healthcare Commercial |
$7,331.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,806.13
|
|
|
pegfilgrastim-cbqv 6 mg/0.6 mL SubQ PFS Inj [VDMC]
|
Facility
|
IP
|
$8,157.76
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
27166716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5,710.43 |
| Max. Negotiated Rate |
$7,341.98 |
| Rate for Payer: Aetna of IA Commercial |
$7,341.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,341.98
|
| Rate for Payer: Cash Price |
$6,526.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,118.32
|
| Rate for Payer: Medical Associates Commercial |
$6,118.32
|
| Rate for Payer: Midlands Choice Commercial |
$5,710.43
|
| Rate for Payer: United Healthcare Commercial |
$7,341.98
|
|
|
pegfilgrastim-cbqv 6 mg/0.6 mL SubQ PFS Inj [VDMC]
|
Facility
|
OP
|
$8,157.76
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
27166716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,077.25 |
| Max. Negotiated Rate |
$7,341.98 |
| Rate for Payer: Aetna of IA Commercial |
$7,341.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,341.98
|
| Rate for Payer: Aetna of IA Medicare |
$4,649.92
|
| Rate for Payer: Amerigroup Medicaid |
$4,117.22
|
| Rate for Payer: Amerigroup Medicare |
$4,119.67
|
| Rate for Payer: Cash Price |
$6,526.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,118.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,078.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,077.25
|
| Rate for Payer: Medical Associates Commercial |
$6,118.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,078.88
|
| Rate for Payer: Midlands Choice Commercial |
$5,710.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,140.06
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$4,137.62
|
| Rate for Payer: Oscar Health of IA Commercial |
$6,118.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,118.32
|
| Rate for Payer: United Healthcare Commercial |
$7,341.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,813.08
|
|
|
pegfilgrastim jmdb 6 mg/0.6 mL inj SDV [VDMC]
|
Facility
|
OP
|
$6,930.20
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
18597654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3,463.71 |
| Max. Negotiated Rate |
$6,237.18 |
| Rate for Payer: Aetna of IA Commercial |
$6,237.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6,237.18
|
| Rate for Payer: Aetna of IA Medicare |
$3,950.21
|
| Rate for Payer: Amerigroup Medicaid |
$3,497.67
|
| Rate for Payer: Amerigroup Medicare |
$3,499.75
|
| Rate for Payer: Cash Price |
$5,544.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5,197.65
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,465.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,463.71
|
| Rate for Payer: Medical Associates Commercial |
$5,197.65
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,465.10
|
| Rate for Payer: Midlands Choice Commercial |
$4,851.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,517.08
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$3,515.00
|
| Rate for Payer: Oscar Health of IA Commercial |
$5,197.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$5,197.65
|
| Rate for Payer: United Healthcare Commercial |
$6,237.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,088.82
|
|
|
pegfilgrastim jmdb 6 mg/0.6 mL inj SDV [VDMC]
|
Facility
|
IP
|
$6,930.20
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
18597654
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,851.14 |
| Max. Negotiated Rate |
$6,237.18 |
| Rate for Payer: Aetna of IA Commercial |
$6,237.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6,237.18
|
| Rate for Payer: Cash Price |
$5,544.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5,197.65
|
| Rate for Payer: Medical Associates Commercial |
$5,197.65
|
| Rate for Payer: Midlands Choice Commercial |
$4,851.14
|
| Rate for Payer: United Healthcare Commercial |
$6,237.18
|
|
|
PEGGED GLENOID POLY W/PEG LARGE
|
Facility
|
IP
|
$2,835.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047277
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,984.50 |
| Max. Negotiated Rate |
$2,551.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,551.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,551.50
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
|
|
PEGGED GLENOID POLY W/PEG LARGE
|
Facility
|
OP
|
$2,835.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047277
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,416.93 |
| Max. Negotiated Rate |
$2,551.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,551.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,551.50
|
| Rate for Payer: Aetna of IA Medicare |
$1,615.95
|
| Rate for Payer: Amerigroup Medicaid |
$1,430.82
|
| Rate for Payer: Amerigroup Medicare |
$1,431.68
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,126.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,417.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,416.93
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,417.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,438.76
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1,437.91
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,126.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,126.25
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,672.65
|
|
|
PEGGED GLENOID POLY W/PEG MEDIUM
|
Facility
|
OP
|
$2,835.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,416.93 |
| Max. Negotiated Rate |
$2,551.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,551.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,551.50
|
| Rate for Payer: Aetna of IA Medicare |
$1,615.95
|
| Rate for Payer: Amerigroup Medicaid |
$1,430.82
|
| Rate for Payer: Amerigroup Medicare |
$1,431.68
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,126.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,417.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,416.93
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,417.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,438.76
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1,437.91
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,126.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,126.25
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,672.65
|
|
|
PEGGED GLENOID POLY W/PEG MEDIUM
|
Facility
|
IP
|
$2,835.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,984.50 |
| Max. Negotiated Rate |
$2,551.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,551.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,551.50
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
|
|
PEGGED GLENOID POLY W/PEG SMALL
|
Facility
|
IP
|
$2,835.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,984.50 |
| Max. Negotiated Rate |
$2,551.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,551.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,551.50
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
|
