|
RENAL PROFILE
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT 80069
|
| Hospital Charge Code |
1634883
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$145.80 |
| Rate for Payer: Aetna of IA Commercial |
$145.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$145.80
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$121.50
|
| Rate for Payer: Medical Associates Commercial |
$121.50
|
| Rate for Payer: Midlands Choice Commercial |
$113.40
|
| Rate for Payer: United Healthcare Commercial |
$145.80
|
|
|
Renin Direct DMCL
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 84244
|
| Hospital Charge Code |
8037795
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
Renin Direct DMCL
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 84244
|
| Hospital Charge Code |
8037795
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
|
|
repaglinide 1 mg Tab [VDMC]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
17838257
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Aetna of IA Medicare |
$0.72
|
| Rate for Payer: Amerigroup Medicaid |
$0.73
|
| Rate for Payer: Amerigroup Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.72
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.57
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.65
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
|
repaglinide 1 mg Tab [VDMC]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
17838257
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
|
|
REPAIR FINGER TENDON
|
Facility
|
IP
|
$1,554.00
|
|
|
Service Code
|
CPT 26418
|
| Hospital Charge Code |
4864867
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,087.80 |
| Max. Negotiated Rate |
$1,398.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,398.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,398.60
|
| Rate for Payer: Cash Price |
$1,243.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,165.50
|
| Rate for Payer: Medical Associates Commercial |
$1,165.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,087.80
|
| Rate for Payer: United Healthcare Commercial |
$1,398.60
|
|
|
REPAIR FINGER TENDON
|
Facility
|
OP
|
$1,554.00
|
|
|
Service Code
|
CPT 26418
|
| Hospital Charge Code |
4864867
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$699.30 |
| Max. Negotiated Rate |
$1,398.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,398.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,398.60
|
| Rate for Payer: Aetna of IA Medicare |
$885.78
|
| Rate for Payer: Amerigroup Medicaid |
$896.35
|
| Rate for Payer: Amerigroup Medicare |
$706.29
|
| Rate for Payer: Cash Price |
$1,243.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,165.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$699.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$887.64
|
| Rate for Payer: Medical Associates Commercial |
$1,165.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$699.30
|
| Rate for Payer: Midlands Choice Commercial |
$1,087.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$900.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$804.20
|
| Rate for Payer: United Healthcare Commercial |
$1,398.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$916.86
|
|
|
REPAIR FOREARM TENDON/MUSCLE
|
Professional
|
Both
|
$1,635.00
|
|
|
Service Code
|
CPT 25270
|
| Hospital Charge Code |
7982870
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$744.80 |
| Max. Negotiated Rate |
$1,226.25 |
| Rate for Payer: Cash Price |
$1,308.00
|
| Rate for Payer: Cash Price |
$1,308.00
|
| Rate for Payer: Medical Associates Commercial |
$1,226.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,144.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,226.25
|
| Rate for Payer: United Healthcare Commercial |
$744.80
|
|
|
REPAIR FOREARM TENDON/MUSCLE
|
Facility
|
OP
|
$3,062.00
|
|
|
Service Code
|
CPT 25270
|
| Hospital Charge Code |
7982923
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,377.90 |
| Max. Negotiated Rate |
$2,755.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,755.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,755.80
|
| Rate for Payer: Aetna of IA Medicare |
$1,745.34
|
| Rate for Payer: Amerigroup Medicaid |
$1,766.16
|
| Rate for Payer: Amerigroup Medicare |
$1,391.68
|
| Rate for Payer: Cash Price |
$2,449.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,296.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,377.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,749.01
|
| Rate for Payer: Medical Associates Commercial |
$2,296.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,377.90
|
| Rate for Payer: Midlands Choice Commercial |
$2,143.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,774.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,584.59
|
| Rate for Payer: United Healthcare Commercial |
$2,755.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,806.58
|
|
|
REPAIR FOREARM TENDON/MUSCLE
|
Facility
|
IP
|
$3,062.00
|
|
|
Service Code
|
CPT 25270
|
| Hospital Charge Code |
7982923
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,143.40 |
| Max. Negotiated Rate |
$2,755.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,755.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,755.80
|
| Rate for Payer: Cash Price |
$2,449.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,296.50
|
| Rate for Payer: Medical Associates Commercial |
$2,296.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,143.40
|
| Rate for Payer: United Healthcare Commercial |
$2,755.80
|
|
|
REPAIR LIP
|
Facility
|
IP
|
$1,663.00
|
|
|
Service Code
|
CPT 40650
|
| Hospital Charge Code |
4864950
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,164.10 |
| Max. Negotiated Rate |
$1,496.70 |
| Rate for Payer: Aetna of IA Commercial |
$1,496.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,496.70
|
| Rate for Payer: Cash Price |
$1,330.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,247.25
|
| Rate for Payer: Medical Associates Commercial |
$1,247.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,164.10
|
| Rate for Payer: United Healthcare Commercial |
$1,496.70
|
|
|
REPAIR LIP
|
Professional
|
Both
|
$1,467.00
|
|
|
Service Code
|
CPT 40650
|
| Hospital Charge Code |
7982775
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$696.32 |
| Max. Negotiated Rate |
$1,100.25 |
| Rate for Payer: Cash Price |
$1,173.60
|
| Rate for Payer: Cash Price |
$1,173.60
|
| Rate for Payer: Medical Associates Commercial |
$1,100.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,026.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,100.25
|
| Rate for Payer: United Healthcare Commercial |
$696.32
|
|
|
REPAIR LIP
|
Facility
|
OP
|
$1,663.00
|
|
|
Service Code
|
CPT 40650
|
| Hospital Charge Code |
4864950
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$748.35 |
| Max. Negotiated Rate |
$1,496.70 |
| Rate for Payer: Aetna of IA Commercial |
$1,496.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,496.70
|
| Rate for Payer: Aetna of IA Medicare |
$947.91
|
| Rate for Payer: Amerigroup Medicaid |
$959.22
|
| Rate for Payer: Amerigroup Medicare |
$755.83
|
| Rate for Payer: Cash Price |
$1,330.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,247.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$748.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$949.91
|
| Rate for Payer: Medical Associates Commercial |
$1,247.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$748.35
|
| Rate for Payer: Midlands Choice Commercial |
$1,164.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$963.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$860.60
|
| Rate for Payer: United Healthcare Commercial |
$1,496.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$981.17
|
|
|
REPAIR OF NAIL BED
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
CPT 11760
|
| Hospital Charge Code |
4863319
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$212.80 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna of IA Commercial |
$273.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$273.60
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.00
|
| Rate for Payer: Medical Associates Commercial |
$228.00
|
| Rate for Payer: Midlands Choice Commercial |
$212.80
|
| Rate for Payer: United Healthcare Commercial |
$273.60
|
|
|
REPAIR OF NAIL BED
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT 11760
|
| Hospital Charge Code |
4863319
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna of IA Commercial |
$273.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$273.60
|
| Rate for Payer: Aetna of IA Medicare |
$173.28
|
| Rate for Payer: Amerigroup Medicaid |
$175.35
|
| Rate for Payer: Amerigroup Medicare |
$138.17
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$136.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$173.64
|
| Rate for Payer: Medical Associates Commercial |
$228.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$136.80
|
| Rate for Payer: Midlands Choice Commercial |
$212.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$176.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$157.32
|
| Rate for Payer: United Healthcare Commercial |
$273.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$179.36
|
|
|
REPAIR OF NAIL BED SIMPLE
|
Professional
|
Both
|
$624.00
|
|
|
Service Code
|
CPT 11760
|
| Hospital Charge Code |
7982846
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$293.57 |
| Max. Negotiated Rate |
$468.00 |
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Medical Associates Commercial |
$468.00
|
| Rate for Payer: Midlands Choice Commercial |
$436.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$468.00
|
| Rate for Payer: United Healthcare Commercial |
$293.57
|
|
|
Respiratory Panel 2.1 (BioFire)
|
Facility
|
IP
|
$661.00
|
|
|
Service Code
|
CPT 87633
|
| Hospital Charge Code |
8789842
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$462.70 |
| Max. Negotiated Rate |
$594.90 |
| Rate for Payer: Aetna of IA Commercial |
$594.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$594.90
|
| Rate for Payer: Cash Price |
$528.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$495.75
|
| Rate for Payer: Medical Associates Commercial |
$495.75
|
| Rate for Payer: Midlands Choice Commercial |
$462.70
|
| Rate for Payer: United Healthcare Commercial |
$594.90
|
|
|
Respiratory Panel 2.1 (BioFire)
|
Facility
|
OP
|
$661.00
|
|
|
Service Code
|
CPT 87633
|
| Hospital Charge Code |
8789842
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$297.45 |
| Max. Negotiated Rate |
$594.90 |
| Rate for Payer: Aetna of IA Commercial |
$594.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$594.90
|
| Rate for Payer: Aetna of IA Medicare |
$376.77
|
| Rate for Payer: Amerigroup Medicaid |
$381.26
|
| Rate for Payer: Amerigroup Medicare |
$300.42
|
| Rate for Payer: Cash Price |
$528.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$495.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$297.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$377.56
|
| Rate for Payer: Medical Associates Commercial |
$495.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$297.45
|
| Rate for Payer: Midlands Choice Commercial |
$462.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$383.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$342.07
|
| Rate for Payer: United Healthcare Commercial |
$594.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$389.99
|
|
|
Respiratory Panel by PCR
|
Facility
|
IP
|
$661.00
|
|
|
Service Code
|
CPT 87633
|
| Hospital Charge Code |
8757579
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$462.70 |
| Max. Negotiated Rate |
$594.90 |
| Rate for Payer: Aetna of IA Commercial |
$594.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$594.90
|
| Rate for Payer: Cash Price |
$528.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$495.75
|
| Rate for Payer: Medical Associates Commercial |
$495.75
|
| Rate for Payer: Midlands Choice Commercial |
$462.70
|
| Rate for Payer: United Healthcare Commercial |
$594.90
|
|
|
Respiratory Panel by PCR
|
Facility
|
OP
|
$661.00
|
|
|
Service Code
|
CPT 87633
|
| Hospital Charge Code |
8757579
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$297.45 |
| Max. Negotiated Rate |
$594.90 |
| Rate for Payer: Aetna of IA Commercial |
$594.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$594.90
|
| Rate for Payer: Aetna of IA Medicare |
$376.77
|
| Rate for Payer: Amerigroup Medicaid |
$381.26
|
| Rate for Payer: Amerigroup Medicare |
$300.42
|
| Rate for Payer: Cash Price |
$528.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$495.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$297.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$377.56
|
| Rate for Payer: Medical Associates Commercial |
$495.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$297.45
|
| Rate for Payer: Midlands Choice Commercial |
$462.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$383.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$342.07
|
| Rate for Payer: United Healthcare Commercial |
$594.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$389.99
|
|
|
Restrata 1x2 soft tissue repair
|
Facility
|
OP
|
$2,925.00
|
|
|
Service Code
|
HCPCS c1713
|
| Hospital Charge Code |
8874155
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,316.25 |
| Max. Negotiated Rate |
$2,632.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,632.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,632.50
|
| Rate for Payer: Aetna of IA Medicare |
$1,667.25
|
| Rate for Payer: Amerigroup Medicaid |
$1,687.14
|
| Rate for Payer: Amerigroup Medicare |
$1,329.41
|
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,193.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,316.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,670.76
|
| Rate for Payer: Medical Associates Commercial |
$2,193.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,316.25
|
| Rate for Payer: Midlands Choice Commercial |
$2,047.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,695.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,513.69
|
| Rate for Payer: United Healthcare Commercial |
$2,632.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,725.75
|
|
|
Restrata 1x2 soft tissue repair
|
Facility
|
IP
|
$2,925.00
|
|
|
Service Code
|
HCPCS c1713
|
| Hospital Charge Code |
8874155
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,047.50 |
| Max. Negotiated Rate |
$2,632.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,632.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,632.50
|
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,193.75
|
| Rate for Payer: Medical Associates Commercial |
$2,193.75
|
| Rate for Payer: Midlands Choice Commercial |
$2,047.50
|
| Rate for Payer: United Healthcare Commercial |
$2,632.50
|
|
|
Restrata 3x3 RMW1
|
Facility
|
OP
|
$6,075.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8942331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,733.75 |
| Max. Negotiated Rate |
$5,467.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,467.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,467.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,462.75
|
| Rate for Payer: Amerigroup Medicaid |
$3,504.06
|
| Rate for Payer: Amerigroup Medicare |
$2,761.09
|
| Rate for Payer: Cash Price |
$4,860.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,556.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,733.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,470.04
|
| Rate for Payer: Medical Associates Commercial |
$4,556.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,733.75
|
| Rate for Payer: Midlands Choice Commercial |
$4,252.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,521.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,143.81
|
| Rate for Payer: United Healthcare Commercial |
$5,467.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,584.25
|
|
|
Restrata 3x3 RMW1
|
Facility
|
IP
|
$6,075.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8942331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,252.50 |
| Max. Negotiated Rate |
$5,467.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,467.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,467.50
|
| Rate for Payer: Cash Price |
$4,860.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,556.25
|
| Rate for Payer: Medical Associates Commercial |
$4,556.25
|
| Rate for Payer: Midlands Choice Commercial |
$4,252.50
|
| Rate for Payer: United Healthcare Commercial |
$5,467.50
|
|
|
RESTRATA 5PK 1X1 5PK 1X2
|
Facility
|
OP
|
$18,497.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8943983
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,323.65 |
| Max. Negotiated Rate |
$16,647.30 |
| Rate for Payer: Aetna of IA Commercial |
$16,647.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16,647.30
|
| Rate for Payer: Aetna of IA Medicare |
$10,543.29
|
| Rate for Payer: Amerigroup Medicaid |
$10,669.07
|
| Rate for Payer: Amerigroup Medicare |
$8,406.89
|
| Rate for Payer: Cash Price |
$14,797.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13,872.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8,323.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10,565.49
|
| Rate for Payer: Medical Associates Commercial |
$13,872.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$8,323.65
|
| Rate for Payer: Midlands Choice Commercial |
$12,947.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,720.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$9,572.20
|
| Rate for Payer: United Healthcare Commercial |
$16,647.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$10,913.23
|
|
