|
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
|
|
|
PLATE AXSOS COMPRESSION LOCKING 10HOLE
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046734
|
|
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 |
$108.68
|
| Rate for Payer: United Healthcare Commercial |
$189.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$123.90
|
|
|
PLATE AXSOS COMPRESSION LOCKING 10HOLE
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046734
|
|
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 AXSOS COMPRESSION LOCKING 4 HOLE
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$65.25 |
| Max. Negotiated Rate |
$130.50 |
| Rate for Payer: Aetna of IA Commercial |
$130.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$130.50
|
| Rate for Payer: Aetna of IA Medicare |
$82.65
|
| Rate for Payer: Amerigroup Medicaid |
$83.64
|
| Rate for Payer: Amerigroup Medicare |
$65.90
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$108.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$65.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$82.82
|
| Rate for Payer: Medical Associates Commercial |
$108.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.25
|
| Rate for Payer: Midlands Choice Commercial |
$101.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$84.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$75.04
|
| Rate for Payer: United Healthcare Commercial |
$130.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$85.55
|
|
|
PLATE AXSOS COMPRESSION LOCKING 4 HOLE
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046730
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$101.50 |
| Max. Negotiated Rate |
$130.50 |
| Rate for Payer: Aetna of IA Commercial |
$130.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$130.50
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$108.75
|
| Rate for Payer: Medical Associates Commercial |
$108.75
|
| Rate for Payer: Midlands Choice Commercial |
$101.50
|
| Rate for Payer: United Healthcare Commercial |
$130.50
|
|
|
PLATE AXSOS COMPRESSION LOCKING 6 HOLE
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$79.65 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of IA Commercial |
$159.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$159.30
|
| Rate for Payer: Aetna of IA Medicare |
$100.89
|
| Rate for Payer: Amerigroup Medicaid |
$102.09
|
| Rate for Payer: Amerigroup Medicare |
$80.45
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$101.10
|
| Rate for Payer: Medical Associates Commercial |
$132.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.65
|
| Rate for Payer: Midlands Choice Commercial |
$123.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.60
|
| Rate for Payer: United Healthcare Commercial |
$159.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$104.43
|
|
|
PLATE AXSOS COMPRESSION LOCKING 6 HOLE
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046731
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of IA Commercial |
$159.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$159.30
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.75
|
| Rate for Payer: Medical Associates Commercial |
$132.75
|
| Rate for Payer: Midlands Choice Commercial |
$123.90
|
| Rate for Payer: United Healthcare Commercial |
$159.30
|
|
|
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
|
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 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 |
$108.68
|
| Rate for Payer: United Healthcare Commercial |
$189.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$123.90
|
|
|
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 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 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
|
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 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 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
|
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 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
|
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 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
|
|
