|
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 |
$79.59 |
| Max. Negotiated Rate |
$102.33 |
| Rate for Payer: Aetna of IA Commercial |
$102.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.33
|
| 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 |
$79.59
|
| Rate for Payer: United Healthcare Commercial |
$102.33
|
|
|
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 |
$51.16 |
| Max. Negotiated Rate |
$102.33 |
| Rate for Payer: Aetna of IA Commercial |
$102.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.33
|
| Rate for Payer: Aetna of IA Medicare |
$64.81
|
| Rate for Payer: Amerigroup Medicaid |
$65.58
|
| Rate for Payer: Amerigroup Medicare |
$51.67
|
| 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 |
$51.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$64.94
|
| Rate for Payer: Medical Associates Commercial |
$85.27
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.16
|
| Rate for Payer: Midlands Choice Commercial |
$79.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$65.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$58.84
|
| Rate for Payer: United Healthcare Commercial |
$102.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.08
|
|
|
patiromer 8.4 g Pow [VDMC]
|
Facility
|
OP
|
$78.57
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
27933279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.36 |
| Max. Negotiated Rate |
$70.71 |
| Rate for Payer: Aetna of IA Commercial |
$70.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.71
|
| Rate for Payer: Aetna of IA Medicare |
$44.78
|
| Rate for Payer: Amerigroup Medicaid |
$45.32
|
| Rate for Payer: Amerigroup Medicare |
$35.71
|
| Rate for Payer: Cash Price |
$62.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.93
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$35.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$44.88
|
| Rate for Payer: Medical Associates Commercial |
$58.93
|
| Rate for Payer: Medical Associates Managed Medicare |
$35.36
|
| Rate for Payer: Midlands Choice Commercial |
$55.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$45.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.66
|
| Rate for Payer: United Healthcare Commercial |
$70.71
|
| Rate for Payer: United Healthcare Managed Medicare |
$46.36
|
|
|
patiromer 8.4 g Pow [VDMC]
|
Facility
|
IP
|
$78.57
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
27933279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$70.71 |
| Rate for Payer: Aetna of IA Commercial |
$70.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.71
|
| Rate for Payer: Cash Price |
$62.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.93
|
| Rate for Payer: Medical Associates Commercial |
$58.93
|
| Rate for Payer: Midlands Choice Commercial |
$55.00
|
| Rate for Payer: United Healthcare Commercial |
$70.71
|
|
|
Peds Med Surg
|
Facility
|
IP
|
$1,300.00
|
|
| Hospital Charge Code |
8002759
|
|
Hospital Revenue Code
|
113
|
| Min. Negotiated Rate |
$910.00 |
| Max. Negotiated Rate |
$2,580.60 |
| 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 |
$2,266.44
|
| 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 |
$2,244.00
|
| Rate for Payer: Medical Associates Commercial |
$975.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,244.00
|
| Rate for Payer: Midlands Choice Commercial |
$910.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,580.60
|
| 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 |
$96.41 |
| 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 |
$123.57
|
| Rate for Payer: Amerigroup Medicare |
$97.37
|
| 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 |
$96.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$122.37
|
| Rate for Payer: Medical Associates Commercial |
$160.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$96.41
|
| Rate for Payer: Midlands Choice Commercial |
$149.97
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$124.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$110.87
|
| 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
|
OP
|
$98.68
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414263
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.41 |
| 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 |
$56.92
|
| Rate for Payer: Amerigroup Medicare |
$44.85
|
| 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 |
$44.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.37
|
| Rate for Payer: Medical Associates Commercial |
$74.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$44.41
|
| Rate for Payer: Midlands Choice Commercial |
$69.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$51.07
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$58.22
|
|
|
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 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 |
$25.40 |
| 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 |
$32.55
|
| Rate for Payer: Amerigroup Medicare |
$25.65
|
| 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 |
$25.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.24
|
| Rate for Payer: Medical Associates Commercial |
$42.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.40
|
| Rate for Payer: Midlands Choice Commercial |
$39.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$29.21
|
| 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
|
$8,399.00
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
10412131
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5,879.30 |
| Max. Negotiated Rate |
$7,559.10 |
| Rate for Payer: Aetna of IA Commercial |
$7,559.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,559.10
|
| Rate for Payer: Cash Price |
$6,719.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,299.25
|
| Rate for Payer: Medical Associates Commercial |
$6,299.25
|
| Rate for Payer: Midlands Choice Commercial |
$5,879.30
|
| Rate for Payer: United Healthcare Commercial |
$7,559.10
|
|
|
pegfilgrastim 6 mg/0.6 mL SubQ SDV Inj [VDMC]
|
Facility
|
OP
|
$8,399.00
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
10412131
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3,779.55 |
| Max. Negotiated Rate |
$7,559.10 |
| Rate for Payer: Aetna of IA Commercial |
$7,559.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,559.10
|
| Rate for Payer: Aetna of IA Medicare |
$4,787.43
|
| Rate for Payer: Amerigroup Medicaid |
$4,844.54
|
| Rate for Payer: Amerigroup Medicare |
$3,817.35
|
| Rate for Payer: Cash Price |
$6,719.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,299.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,779.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,797.51
|
| Rate for Payer: Medical Associates Commercial |
$6,299.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,779.55
|
| Rate for Payer: Midlands Choice Commercial |
$5,879.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,868.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,346.48
|
| Rate for Payer: United Healthcare Commercial |
$7,559.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,955.41
|
|
|
pegfilgrastim-apgf 6 mg/0.6 mL SubQ PFS Inj [VDMC]
|
Facility
|
IP
|
$7,675.26
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
27690722
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5,372.68 |
| Max. Negotiated Rate |
$6,907.73 |
| Rate for Payer: Aetna of IA Commercial |
$6,907.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6,907.73
|
| Rate for Payer: Cash Price |
$6,140.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5,756.44
|
| Rate for Payer: Medical Associates Commercial |
$5,756.44
|
| Rate for Payer: Midlands Choice Commercial |
$5,372.68
|
| Rate for Payer: United Healthcare Commercial |
$6,907.73
|
|
|
pegfilgrastim-apgf 6 mg/0.6 mL SubQ PFS Inj [VDMC]
|
Facility
|
OP
|
$7,675.26
|
|
|
Service Code
|
HCPCS Q5122
|
| Hospital Charge Code |
27690722
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3,453.87 |
| Max. Negotiated Rate |
$6,907.73 |
| Rate for Payer: Aetna of IA Commercial |
$6,907.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6,907.73
|
| Rate for Payer: Aetna of IA Medicare |
$4,374.90
|
| Rate for Payer: Amerigroup Medicaid |
$4,427.09
|
| Rate for Payer: Amerigroup Medicare |
$3,488.41
|
| Rate for Payer: Cash Price |
$6,140.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5,756.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,453.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,384.11
|
| Rate for Payer: Medical Associates Commercial |
$5,756.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,453.87
|
| Rate for Payer: Midlands Choice Commercial |
$5,372.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,448.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,971.95
|
| Rate for Payer: United Healthcare Commercial |
$6,907.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,528.40
|
|
|
pegfilgrastim-jmdb 6 mg/0.6 mL SubQ PFS Inj[VDMC]
|
Facility
|
IP
|
$3,458.20
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
28403492
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,420.74 |
| Max. Negotiated Rate |
$3,112.38 |
| Rate for Payer: Aetna of IA Commercial |
$3,112.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,112.38
|
| Rate for Payer: Cash Price |
$2,766.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,593.65
|
| Rate for Payer: Medical Associates Commercial |
$2,593.65
|
| Rate for Payer: Midlands Choice Commercial |
$2,420.74
|
| Rate for Payer: United Healthcare Commercial |
$3,112.38
|
|
|
pegfilgrastim-jmdb 6 mg/0.6 mL SubQ PFS Inj[VDMC]
|
Facility
|
OP
|
$3,458.20
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
28403492
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,556.19 |
| Max. Negotiated Rate |
$3,112.38 |
| Rate for Payer: Aetna of IA Commercial |
$3,112.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,112.38
|
| Rate for Payer: Aetna of IA Medicare |
$1,971.17
|
| Rate for Payer: Amerigroup Medicaid |
$1,994.69
|
| Rate for Payer: Amerigroup Medicare |
$1,571.75
|
| Rate for Payer: Cash Price |
$2,766.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,593.65
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,556.19
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,975.32
|
| Rate for Payer: Medical Associates Commercial |
$2,593.65
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,556.19
|
| Rate for Payer: Midlands Choice Commercial |
$2,420.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,004.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,789.62
|
| Rate for Payer: United Healthcare Commercial |
$3,112.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,040.34
|
|
|
PEGGED GLENOID POLY W/PEG LARGE
|
Facility
|
OP
|
$2,835.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
8047277
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.75 |
| 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 |
$1,635.23
|
| Rate for Payer: Amerigroup Medicare |
$1,288.51
|
| 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 |
$1,275.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,619.35
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,275.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,643.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,467.11
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,672.65
|
|
|
PEGGED GLENOID POLY W/PEG LARGE
|
Facility
|
IP
|
$2,835.00
|
|
|
Service Code
|
HCPCS 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 MEDIUM
|
Facility
|
IP
|
$2,835.00
|
|
|
Service Code
|
HCPCS 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 MEDIUM
|
Facility
|
OP
|
$2,835.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
8047276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.75 |
| 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 |
$1,635.23
|
| Rate for Payer: Amerigroup Medicare |
$1,288.51
|
| 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 |
$1,275.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,619.35
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,275.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,643.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,467.11
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,672.65
|
|
|
PEGGED GLENOID POLY W/PEG SMALL
|
Facility
|
OP
|
$2,835.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
8047275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.75 |
| 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 |
$1,635.23
|
| Rate for Payer: Amerigroup Medicare |
$1,288.51
|
| 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 |
$1,275.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,619.35
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,275.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,643.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,467.11
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,672.65
|
|
|
PEGGED GLENOID POLY W/PEG SMALL
|
Facility
|
IP
|
$2,835.00
|
|
|
Service Code
|
HCPCS 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
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC
|
Facility
|
IP
|
$19,258.71
|
|
|
Service Code
|
MSDRG 734
|
| Min. Negotiated Rate |
$18,979.59 |
| Max. Negotiated Rate |
$19,258.71 |
| Rate for Payer: Amerigroup Medicaid |
$19,165.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18,979.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19,258.71
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$18,640.55
|
|
|
Service Code
|
MSDRG 735
|
| Min. Negotiated Rate |
$18,370.39 |
| Max. Negotiated Rate |
$18,640.55 |
| Rate for Payer: Amerigroup Medicaid |
$18,550.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18,370.39
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18,640.55
|
|
