|
piperacillin-tazobactam 3 g-0.375 g IV SDV Inj [VDMC]
|
Facility
|
IP
|
$27.35
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
10413855
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Aetna of IA Commercial |
$24.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.61
|
| Rate for Payer: Cash Price |
$21.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.51
|
| Rate for Payer: Medical Associates Commercial |
$20.51
|
| Rate for Payer: Midlands Choice Commercial |
$19.14
|
| Rate for Payer: United Healthcare Commercial |
$24.61
|
|
|
piperacillin-tazobactam 3 g-0.375 g IV SDV Inj [VDMC]
|
Facility
|
OP
|
$27.35
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
10413855
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.31 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$24.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.61
|
| Rate for Payer: Aetna of IA Medicare |
$15.59
|
| Rate for Payer: Amerigroup Medicaid |
$15.77
|
| Rate for Payer: Amerigroup Medicare |
$12.43
|
| Rate for Payer: Cash Price |
$21.88
|
| Rate for Payer: Cash Price |
$21.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.62
|
| Rate for Payer: Medical Associates Commercial |
$20.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.31
|
| Rate for Payer: Midlands Choice Commercial |
$19.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.15
|
| Rate for Payer: United Healthcare Commercial |
$24.61
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.14
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
piperacillin-tazobactam 4 g-0.5 g IV SDV Inj [VDMC]
|
Facility
|
OP
|
$30.82
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
10413924
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.87 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$27.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.74
|
| Rate for Payer: Aetna of IA Medicare |
$17.57
|
| Rate for Payer: Amerigroup Medicaid |
$17.78
|
| Rate for Payer: Amerigroup Medicare |
$14.01
|
| Rate for Payer: Cash Price |
$24.66
|
| Rate for Payer: Cash Price |
$24.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.60
|
| Rate for Payer: Medical Associates Commercial |
$23.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.87
|
| Rate for Payer: Midlands Choice Commercial |
$21.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.95
|
| Rate for Payer: United Healthcare Commercial |
$27.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.18
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
piperacillin-tazobactam 4 g-0.5 g IV SDV Inj [VDMC]
|
Facility
|
IP
|
$30.82
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
10413924
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$27.74 |
| Rate for Payer: Aetna of IA Commercial |
$27.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.74
|
| Rate for Payer: Cash Price |
$24.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.12
|
| Rate for Payer: Medical Associates Commercial |
$23.12
|
| Rate for Payer: Midlands Choice Commercial |
$21.57
|
| Rate for Payer: United Healthcare Commercial |
$27.74
|
|
|
piroxicam 20 mg Cap [VDMC]
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10413993
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Aetna of IA Commercial |
$2.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.69
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.24
|
| Rate for Payer: Medical Associates Commercial |
$2.24
|
| Rate for Payer: Midlands Choice Commercial |
$2.09
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
|
|
piroxicam 20 mg Cap [VDMC]
|
Facility
|
OP
|
$2.99
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10413993
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Aetna of IA Commercial |
$2.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.69
|
| Rate for Payer: Aetna of IA Medicare |
$1.70
|
| Rate for Payer: Amerigroup Medicaid |
$1.72
|
| Rate for Payer: Amerigroup Medicare |
$1.36
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.71
|
| Rate for Payer: Medical Associates Commercial |
$2.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.35
|
| Rate for Payer: Midlands Choice Commercial |
$2.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.76
|
|
|
PLATE 10 HOLE DYNAMIC COMP
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046462
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$192.50 |
| Max. Negotiated Rate |
$247.50 |
| Rate for Payer: Aetna of IA Commercial |
$247.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$247.50
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$206.25
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: United Healthcare Commercial |
$247.50
|
|
|
PLATE 10 HOLE DYNAMIC COMP
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046462
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$123.75 |
| Max. Negotiated Rate |
$247.50 |
| Rate for Payer: Aetna of IA Commercial |
$247.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$247.50
|
| Rate for Payer: Aetna of IA Medicare |
$156.75
|
| Rate for Payer: Amerigroup Medicaid |
$158.62
|
| Rate for Payer: Amerigroup Medicare |
$124.99
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$206.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$123.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$157.08
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$123.75
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$159.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$142.31
|
| Rate for Payer: United Healthcare Commercial |
$247.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$162.25
|
|
|
PLATE 5 DISTAL LATERAL FIBULA
|
Facility
|
OP
|
$884.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
8046706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$397.80 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna of IA Commercial |
$795.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$795.60
|
| Rate for Payer: Aetna of IA Medicare |
$503.88
|
| Rate for Payer: Amerigroup Medicaid |
$509.89
|
| Rate for Payer: Amerigroup Medicare |
$401.78
|
| Rate for Payer: Cash Price |
$707.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$663.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$397.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$504.94
|
| Rate for Payer: Medical Associates Commercial |
$663.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$397.80
|
| Rate for Payer: Midlands Choice Commercial |
$618.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$512.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$457.47
|
| Rate for Payer: United Healthcare Commercial |
$795.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$521.56
|
|
|
PLATE 5 DISTAL LATERAL FIBULA
|
Facility
|
IP
|
$884.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
8046706
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.80 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna of IA Commercial |
$795.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$795.60
|
| Rate for Payer: Cash Price |
$707.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$663.00
|
| Rate for Payer: Medical Associates Commercial |
$663.00
|
| Rate for Payer: Midlands Choice Commercial |
$618.80
|
| Rate for Payer: United Healthcare Commercial |
$795.60
|
|
|
PLATE 5 HOLE SM FRAGMENT
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna of IA Commercial |
$117.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.00
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$97.50
|
| Rate for Payer: Medical Associates Commercial |
$97.50
|
| Rate for Payer: Midlands Choice Commercial |
$91.00
|
| Rate for Payer: United Healthcare Commercial |
$117.00
|
|
|
PLATE 5 HOLE SM FRAGMENT
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna of IA Commercial |
$117.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.00
|
| Rate for Payer: Aetna of IA Medicare |
$74.10
|
| Rate for Payer: Amerigroup Medicaid |
$74.98
|
| Rate for Payer: Amerigroup Medicare |
$59.08
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$97.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.26
|
| Rate for Payer: Medical Associates Commercial |
$97.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.50
|
| Rate for Payer: Midlands Choice Commercial |
$91.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$75.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$67.28
|
| Rate for Payer: United Healthcare Commercial |
$117.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.70
|
|
|
PLATE 5TH MET HOOK LEFT
|
Facility
|
IP
|
$2,070.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
8793247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.00 |
| Max. Negotiated Rate |
$1,863.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,863.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,863.00
|
| Rate for Payer: Cash Price |
$1,656.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,552.50
|
| Rate for Payer: Medical Associates Commercial |
$1,552.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,449.00
|
| Rate for Payer: United Healthcare Commercial |
$1,863.00
|
|
|
PLATE 5TH MET HOOK LEFT
|
Facility
|
OP
|
$2,070.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
8793247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$931.50 |
| Max. Negotiated Rate |
$1,863.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,863.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,863.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,179.90
|
| Rate for Payer: Amerigroup Medicaid |
$1,193.98
|
| Rate for Payer: Amerigroup Medicare |
$940.82
|
| Rate for Payer: Cash Price |
$1,656.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,552.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$931.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,182.38
|
| Rate for Payer: Medical Associates Commercial |
$1,552.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$931.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,449.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,199.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,071.22
|
| Rate for Payer: United Healthcare Commercial |
$1,863.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,221.30
|
|
|
PLATE 6 HOLE DYNAMIC COMP
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046314
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$177.80 |
| Max. Negotiated Rate |
$228.60 |
| Rate for Payer: Aetna of IA Commercial |
$228.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$228.60
|
| Rate for Payer: Cash Price |
$203.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$190.50
|
| Rate for Payer: Medical Associates Commercial |
$190.50
|
| Rate for Payer: Midlands Choice Commercial |
$177.80
|
| Rate for Payer: United Healthcare Commercial |
$228.60
|
|
|
PLATE 6 HOLE DYNAMIC COMP
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046314
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$114.30 |
| Max. Negotiated Rate |
$228.60 |
| Rate for Payer: Aetna of IA Commercial |
$228.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$228.60
|
| Rate for Payer: Aetna of IA Medicare |
$144.78
|
| Rate for Payer: Amerigroup Medicaid |
$146.51
|
| Rate for Payer: Amerigroup Medicare |
$115.44
|
| Rate for Payer: Cash Price |
$203.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$190.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$114.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$145.08
|
| Rate for Payer: Medical Associates Commercial |
$190.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$114.30
|
| Rate for Payer: Midlands Choice Commercial |
$177.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$147.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$131.44
|
| Rate for Payer: United Healthcare Commercial |
$228.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$149.86
|
|
|
PLATE 6 HOLE SM FRAGMENT
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
|
|
PLATE 6 HOLE SM FRAGMENT
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046719
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Aetna of IA Medicare |
$73.53
|
| Rate for Payer: Amerigroup Medicaid |
$74.41
|
| Rate for Payer: Amerigroup Medicare |
$58.63
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.68
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.05
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$66.76
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
|
|
PLATE 7 HOLE DYNAMIC COMP
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046393
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$123.75 |
| Max. Negotiated Rate |
$247.50 |
| Rate for Payer: Aetna of IA Commercial |
$247.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$247.50
|
| Rate for Payer: Aetna of IA Medicare |
$156.75
|
| Rate for Payer: Amerigroup Medicaid |
$158.62
|
| Rate for Payer: Amerigroup Medicare |
$124.99
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$206.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$123.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$157.08
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$123.75
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$159.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$142.31
|
| Rate for Payer: United Healthcare Commercial |
$247.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$162.25
|
|
|
PLATE 7 HOLE DYNAMIC COMP
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046393
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$192.50 |
| Max. Negotiated Rate |
$247.50 |
| Rate for Payer: Aetna of IA Commercial |
$247.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$247.50
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$206.25
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: United Healthcare Commercial |
$247.50
|
|
|
PLATE 7 HOLE SM FRAGMENT
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS Q4107
|
| Hospital Charge Code |
8046723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
|
|
PLATE 7 HOLE SM FRAGMENT
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS Q4107
|
| Hospital Charge Code |
8046723
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Aetna of IA Medicare |
$73.53
|
| Rate for Payer: Amerigroup Medicaid |
$74.41
|
| Rate for Payer: Amerigroup Medicare |
$58.63
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.68
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.05
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$66.76
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
|
|
PLATE 8 HOLE DYNAMIC COMP
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046318
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$123.75 |
| Max. Negotiated Rate |
$247.50 |
| Rate for Payer: Aetna of IA Commercial |
$247.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$247.50
|
| Rate for Payer: Aetna of IA Medicare |
$156.75
|
| Rate for Payer: Amerigroup Medicaid |
$158.62
|
| Rate for Payer: Amerigroup Medicare |
$124.99
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$206.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$123.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$157.08
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$123.75
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$159.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$142.31
|
| Rate for Payer: United Healthcare Commercial |
$247.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$162.25
|
|
|
PLATE 8 HOLE DYNAMIC COMP
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046318
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$192.50 |
| Max. Negotiated Rate |
$247.50 |
| Rate for Payer: Aetna of IA Commercial |
$247.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$247.50
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$206.25
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: United Healthcare Commercial |
$247.50
|
|
|
PLATE 8 HOLE SM FRAGMENT
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046720
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$93.80 |
| Max. Negotiated Rate |
$120.60 |
| Rate for Payer: Aetna of IA Commercial |
$120.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$120.60
|
| Rate for Payer: Cash Price |
$107.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$100.50
|
| Rate for Payer: Medical Associates Commercial |
$100.50
|
| Rate for Payer: Midlands Choice Commercial |
$93.80
|
| Rate for Payer: United Healthcare Commercial |
$120.60
|
|
