|
PLATE AXSOS COMPRESSION LOCKING 7 HOLE
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
8046732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.95 |
| Max. Negotiated Rate |
$207.90 |
| Rate for Payer: Aetna of IA Commercial |
$207.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.90
|
| Rate for Payer: Aetna of IA Medicare |
$131.67
|
| Rate for Payer: Amerigroup Medicaid |
$133.24
|
| Rate for Payer: Amerigroup Medicare |
$104.99
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$173.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$103.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$131.95
|
| Rate for Payer: Medical Associates Commercial |
$173.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$103.95
|
| Rate for Payer: Midlands Choice Commercial |
$161.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$133.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$119.54
|
| Rate for Payer: United Healthcare Commercial |
$207.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$136.29
|
|
|
PLATE AXSOS COMPRESSION LOCKING 7 HOLE
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
8046732
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$207.90 |
| Rate for Payer: Aetna of IA Commercial |
$207.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.90
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$173.25
|
| Rate for Payer: Medical Associates Commercial |
$173.25
|
| Rate for Payer: Midlands Choice Commercial |
$161.70
|
| Rate for Payer: United Healthcare Commercial |
$207.90
|
|
|
PLATE AXSOS COMPRESSION LOCKING 8 HOLE
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna of IA Commercial |
$189.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$189.00
|
| Rate for Payer: Aetna of IA Medicare |
$119.70
|
| Rate for Payer: Amerigroup Medicaid |
$121.13
|
| Rate for Payer: Amerigroup Medicare |
$95.44
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$157.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$94.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$119.95
|
| Rate for Payer: Medical Associates Commercial |
$157.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$94.50
|
| Rate for Payer: Midlands Choice Commercial |
$147.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$121.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$108.67
|
| Rate for Payer: United Healthcare Commercial |
$189.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$123.90
|
|
|
PLATE AXSOS COMPRESSION LOCKING 8 HOLE
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046733
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna of IA Commercial |
$189.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$189.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$157.50
|
| Rate for Payer: Medical Associates Commercial |
$157.50
|
| Rate for Payer: Midlands Choice Commercial |
$147.00
|
| Rate for Payer: United Healthcare Commercial |
$189.00
|
|
|
PLATE CURVED 4 HOLE
|
Facility
|
IP
|
$1,294.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$905.80 |
| Max. Negotiated Rate |
$1,164.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,164.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,164.60
|
| Rate for Payer: Cash Price |
$1,035.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$970.50
|
| Rate for Payer: Medical Associates Commercial |
$970.50
|
| Rate for Payer: Midlands Choice Commercial |
$905.80
|
| Rate for Payer: United Healthcare Commercial |
$1,164.60
|
|
|
PLATE CURVED 4 HOLE
|
Facility
|
OP
|
$1,294.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046705
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$582.30 |
| Max. Negotiated Rate |
$1,164.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,164.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,164.60
|
| Rate for Payer: Aetna of IA Medicare |
$737.58
|
| Rate for Payer: Amerigroup Medicaid |
$746.38
|
| Rate for Payer: Amerigroup Medicare |
$588.12
|
| Rate for Payer: Cash Price |
$1,035.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$970.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$582.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$739.13
|
| Rate for Payer: Medical Associates Commercial |
$970.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$582.30
|
| Rate for Payer: Midlands Choice Commercial |
$905.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$750.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$669.64
|
| Rate for Payer: United Healthcare Commercial |
$1,164.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$763.46
|
|
|
PLATE DISTAL VOLAR RADIUS 3 HOLE
|
Facility
|
OP
|
$896.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$403.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of IA Commercial |
$806.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$806.40
|
| Rate for Payer: Aetna of IA Medicare |
$510.72
|
| Rate for Payer: Amerigroup Medicaid |
$516.81
|
| Rate for Payer: Amerigroup Medicare |
$407.23
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$672.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$403.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$511.80
|
| Rate for Payer: Medical Associates Commercial |
$672.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$403.20
|
| Rate for Payer: Midlands Choice Commercial |
$627.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$519.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$463.68
|
| Rate for Payer: United Healthcare Commercial |
$806.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$528.64
|
|
|
PLATE DISTAL VOLAR RADIUS 3 HOLE
|
Facility
|
IP
|
$896.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of IA Commercial |
$806.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$806.40
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$672.00
|
| Rate for Payer: Medical Associates Commercial |
$672.00
|
| Rate for Payer: Midlands Choice Commercial |
$627.20
|
| Rate for Payer: United Healthcare Commercial |
$806.40
|
|
|
PLATE DISTAL VOLAR RADIUS 3 HOLE RIGHT
|
Facility
|
IP
|
$896.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of IA Commercial |
$806.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$806.40
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$672.00
|
| Rate for Payer: Medical Associates Commercial |
$672.00
|
| Rate for Payer: Midlands Choice Commercial |
$627.20
|
| Rate for Payer: United Healthcare Commercial |
$806.40
|
|
|
PLATE DISTAL VOLAR RADIUS 3 HOLE RIGHT
|
Facility
|
OP
|
$896.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046779
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$403.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of IA Commercial |
$806.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$806.40
|
| Rate for Payer: Aetna of IA Medicare |
$510.72
|
| Rate for Payer: Amerigroup Medicaid |
$516.81
|
| Rate for Payer: Amerigroup Medicare |
$407.23
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$672.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$403.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$511.80
|
| Rate for Payer: Medical Associates Commercial |
$672.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$403.20
|
| Rate for Payer: Midlands Choice Commercial |
$627.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$519.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$463.68
|
| Rate for Payer: United Healthcare Commercial |
$806.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$528.64
|
|
|
PLATE DISTAL VOLAR RADIUS 4 HOLE
|
Facility
|
OP
|
$896.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$403.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of IA Commercial |
$806.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$806.40
|
| Rate for Payer: Aetna of IA Medicare |
$510.72
|
| Rate for Payer: Amerigroup Medicaid |
$516.81
|
| Rate for Payer: Amerigroup Medicare |
$407.23
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$672.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$403.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$511.80
|
| Rate for Payer: Medical Associates Commercial |
$672.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$403.20
|
| Rate for Payer: Midlands Choice Commercial |
$627.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$519.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$463.68
|
| Rate for Payer: United Healthcare Commercial |
$806.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$528.64
|
|
|
PLATE DISTAL VOLAR RADIUS 4 HOLE
|
Facility
|
IP
|
$896.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046778
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of IA Commercial |
$806.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$806.40
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$672.00
|
| Rate for Payer: Medical Associates Commercial |
$672.00
|
| Rate for Payer: Midlands Choice Commercial |
$627.20
|
| Rate for Payer: United Healthcare Commercial |
$806.40
|
|
|
PLATE DISTAL VOLAR RADIUS 4 HOLE RIGHT
|
Facility
|
IP
|
$896.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of IA Commercial |
$806.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$806.40
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$672.00
|
| Rate for Payer: Medical Associates Commercial |
$672.00
|
| Rate for Payer: Midlands Choice Commercial |
$627.20
|
| Rate for Payer: United Healthcare Commercial |
$806.40
|
|
|
PLATE DISTAL VOLAR RADIUS 4 HOLE RIGHT
|
Facility
|
OP
|
$896.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046780
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$403.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of IA Commercial |
$806.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$806.40
|
| Rate for Payer: Aetna of IA Medicare |
$510.72
|
| Rate for Payer: Amerigroup Medicaid |
$516.81
|
| Rate for Payer: Amerigroup Medicare |
$407.23
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$672.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$403.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$511.80
|
| Rate for Payer: Medical Associates Commercial |
$672.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$403.20
|
| Rate for Payer: Midlands Choice Commercial |
$627.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$519.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$463.68
|
| Rate for Payer: United Healthcare Commercial |
$806.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$528.64
|
|
|
PLATE GLENOID BASE (ORTHO)
|
Facility
|
IP
|
$4,070.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
8047297
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,849.00 |
| Max. Negotiated Rate |
$3,663.00 |
| Rate for Payer: Aetna of IA Commercial |
$3,663.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,663.00
|
| Rate for Payer: Cash Price |
$3,256.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,052.50
|
| Rate for Payer: Medical Associates Commercial |
$3,052.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,849.00
|
| Rate for Payer: United Healthcare Commercial |
$3,663.00
|
|
|
PLATE GLENOID BASE (ORTHO)
|
Facility
|
OP
|
$4,070.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
8047297
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,831.50 |
| Max. Negotiated Rate |
$3,663.00 |
| Rate for Payer: Aetna of IA Commercial |
$3,663.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,663.00
|
| Rate for Payer: Aetna of IA Medicare |
$2,319.90
|
| Rate for Payer: Amerigroup Medicaid |
$2,347.58
|
| Rate for Payer: Amerigroup Medicare |
$1,849.82
|
| Rate for Payer: Cash Price |
$3,256.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,052.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,831.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,324.78
|
| Rate for Payer: Medical Associates Commercial |
$3,052.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,831.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,849.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,358.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,106.22
|
| Rate for Payer: United Healthcare Commercial |
$3,663.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,401.30
|
|
|
PLATE IMPLANT 5 DEGREE MEDIUM LEFT
|
Facility
|
IP
|
$2,641.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047367
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,848.70 |
| Max. Negotiated Rate |
$2,376.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,376.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,376.90
|
| Rate for Payer: Cash Price |
$2,112.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,980.75
|
| Rate for Payer: Medical Associates Commercial |
$1,980.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,848.70
|
| Rate for Payer: United Healthcare Commercial |
$2,376.90
|
|
|
PLATE IMPLANT 5 DEGREE MEDIUM LEFT
|
Facility
|
OP
|
$2,641.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047367
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,188.45 |
| Max. Negotiated Rate |
$2,376.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,376.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,376.90
|
| Rate for Payer: Aetna of IA Medicare |
$1,505.37
|
| Rate for Payer: Amerigroup Medicaid |
$1,523.33
|
| Rate for Payer: Amerigroup Medicare |
$1,200.33
|
| Rate for Payer: Cash Price |
$2,112.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,980.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,188.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,508.54
|
| Rate for Payer: Medical Associates Commercial |
$1,980.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,188.45
|
| Rate for Payer: Midlands Choice Commercial |
$1,848.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,530.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,366.72
|
| Rate for Payer: United Healthcare Commercial |
$2,376.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,558.19
|
|
|
PLATE IMPLANT SHORT
|
Facility
|
OP
|
$2,057.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046987
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$925.65 |
| Max. Negotiated Rate |
$1,851.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,851.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,851.30
|
| Rate for Payer: Aetna of IA Medicare |
$1,172.49
|
| Rate for Payer: Amerigroup Medicaid |
$1,186.48
|
| Rate for Payer: Amerigroup Medicare |
$934.91
|
| Rate for Payer: Cash Price |
$1,645.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,542.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$925.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,174.96
|
| Rate for Payer: Medical Associates Commercial |
$1,542.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$925.65
|
| Rate for Payer: Midlands Choice Commercial |
$1,439.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,192.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,064.50
|
| Rate for Payer: United Healthcare Commercial |
$1,851.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,213.63
|
|
|
PLATE IMPLANT SHORT
|
Facility
|
IP
|
$2,057.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046987
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.90 |
| Max. Negotiated Rate |
$1,851.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,851.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,851.30
|
| Rate for Payer: Cash Price |
$1,645.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,542.75
|
| Rate for Payer: Medical Associates Commercial |
$1,542.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,439.90
|
| Rate for Payer: United Healthcare Commercial |
$1,851.30
|
|
|
PLATE LCOKING DELTOID AVULSION, SS, 3H
|
Facility
|
OP
|
$1,114.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.30 |
| Max. Negotiated Rate |
$1,002.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,002.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,002.60
|
| Rate for Payer: Aetna of IA Medicare |
$634.98
|
| Rate for Payer: Amerigroup Medicaid |
$642.56
|
| Rate for Payer: Amerigroup Medicare |
$506.31
|
| Rate for Payer: Cash Price |
$891.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$835.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$501.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$636.32
|
| Rate for Payer: Medical Associates Commercial |
$835.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$501.30
|
| Rate for Payer: Midlands Choice Commercial |
$779.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$645.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$576.50
|
| Rate for Payer: United Healthcare Commercial |
$1,002.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$657.26
|
|
|
PLATE LCOKING DELTOID AVULSION, SS, 3H
|
Facility
|
IP
|
$1,114.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$779.80 |
| Max. Negotiated Rate |
$1,002.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,002.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,002.60
|
| Rate for Payer: Cash Price |
$891.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$835.50
|
| Rate for Payer: Medical Associates Commercial |
$835.50
|
| Rate for Payer: Midlands Choice Commercial |
$779.80
|
| Rate for Payer: United Healthcare Commercial |
$1,002.60
|
|
|
Platelet Antibody Indirect DMCL
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
8037754
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
Platelet Antibody Indirect DMCL
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
8037754
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
PLATELET COUNT
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 85049
|
| Hospital Charge Code |
2182297
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of IA Commercial |
$43.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.20
|
| Rate for Payer: Aetna of IA Medicare |
$27.36
|
| Rate for Payer: Amerigroup Medicaid |
$27.69
|
| Rate for Payer: Amerigroup Medicare |
$21.82
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27.42
|
| Rate for Payer: Medical Associates Commercial |
$36.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.60
|
| Rate for Payer: Midlands Choice Commercial |
$33.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.84
|
| Rate for Payer: United Healthcare Commercial |
$43.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.32
|
|
