|
PLATE IMPLANT SHORT
|
Facility
|
OP
|
$2,057.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046987
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$925.65 |
| Max. Negotiated Rate |
$1,851.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,851.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,851.30
|
| Rate for Payer: Aetna of IA Medicare |
$1,172.49
|
| Rate for Payer: Amerigroup Medicaid |
$1,186.48
|
| Rate for Payer: Amerigroup Medicare |
$934.91
|
| Rate for Payer: Cash Price |
$1,645.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,542.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$925.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,174.96
|
| Rate for Payer: Medical Associates Commercial |
$1,542.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$925.65
|
| Rate for Payer: Midlands Choice Commercial |
$1,439.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,192.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,064.50
|
| Rate for Payer: United Healthcare Commercial |
$1,851.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,213.63
|
|
|
PLATE IMPLANT SHORT
|
Facility
|
IP
|
$2,057.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046987
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.90 |
| Max. Negotiated Rate |
$1,851.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,851.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,851.30
|
| Rate for Payer: Cash Price |
$1,645.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,542.75
|
| Rate for Payer: Medical Associates Commercial |
$1,542.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,439.90
|
| Rate for Payer: United Healthcare Commercial |
$1,851.30
|
|
|
PLATE LCOKING DELTOID AVULSION, SS, 3H
|
Facility
|
OP
|
$1,114.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.30 |
| Max. Negotiated Rate |
$1,002.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,002.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,002.60
|
| Rate for Payer: Aetna of IA Medicare |
$634.98
|
| Rate for Payer: Amerigroup Medicaid |
$642.56
|
| Rate for Payer: Amerigroup Medicare |
$506.31
|
| Rate for Payer: Cash Price |
$891.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$835.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$501.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$636.32
|
| Rate for Payer: Medical Associates Commercial |
$835.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$501.30
|
| Rate for Payer: Midlands Choice Commercial |
$779.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$645.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$576.50
|
| Rate for Payer: United Healthcare Commercial |
$1,002.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$657.26
|
|
|
PLATE LCOKING DELTOID AVULSION, SS, 3H
|
Facility
|
IP
|
$1,114.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047166
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$779.80 |
| Max. Negotiated Rate |
$1,002.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,002.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,002.60
|
| Rate for Payer: Cash Price |
$891.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$835.50
|
| Rate for Payer: Medical Associates Commercial |
$835.50
|
| Rate for Payer: Midlands Choice Commercial |
$779.80
|
| Rate for Payer: United Healthcare Commercial |
$1,002.60
|
|
|
Platelet Antibody Indirect DMCL
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
8037754
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$41.83 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of IA Commercial |
$157.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$157.50
|
| Rate for Payer: Aetna of IA Medicare |
$99.75
|
| Rate for Payer: Amerigroup Medicaid |
$100.94
|
| Rate for Payer: Amerigroup Medicare |
$79.54
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$131.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$78.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$99.96
|
| Rate for Payer: Medical Associates Commercial |
$131.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$78.75
|
| Rate for Payer: Midlands Choice Commercial |
$122.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$101.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$90.56
|
| Rate for Payer: United Healthcare Commercial |
$157.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.25
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
Platelet Antibody Indirect DMCL
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 86022
|
| Hospital Charge Code |
8037754
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of IA Commercial |
$157.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$157.50
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$131.25
|
| Rate for Payer: Medical Associates Commercial |
$131.25
|
| Rate for Payer: Midlands Choice Commercial |
$122.50
|
| Rate for Payer: United Healthcare Commercial |
$157.50
|
|
|
PLATELET COUNT
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT 85049
|
| Hospital Charge Code |
2182297
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of IA Commercial |
$43.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.20
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.00
|
| Rate for Payer: Medical Associates Commercial |
$36.00
|
| Rate for Payer: Midlands Choice Commercial |
$33.60
|
| Rate for Payer: United Healthcare Commercial |
$43.20
|
|
|
PLATELET COUNT
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 85049
|
| Hospital Charge Code |
2182297
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of IA Commercial |
$43.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.20
|
| Rate for Payer: Aetna of IA Medicare |
$27.36
|
| Rate for Payer: Amerigroup Medicaid |
$27.69
|
| Rate for Payer: Amerigroup Medicare |
$21.82
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27.42
|
| Rate for Payer: Medical Associates Commercial |
$36.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.60
|
| Rate for Payer: Midlands Choice Commercial |
$33.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.84
|
| Rate for Payer: United Healthcare Commercial |
$43.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.32
|
| Rate for Payer: Wellmark IA HMO WHPI |
$29.07
|
| Rate for Payer: Wellmark IA PPO |
$32.02
|
|
|
PLATE LOCKING AXSOS RECON 10 HOLE L120
|
Facility
|
IP
|
$635.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$444.50 |
| Max. Negotiated Rate |
$571.50 |
| Rate for Payer: Aetna of IA Commercial |
$571.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$571.50
|
| Rate for Payer: Cash Price |
$508.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$476.25
|
| Rate for Payer: Medical Associates Commercial |
$476.25
|
| Rate for Payer: Midlands Choice Commercial |
$444.50
|
| Rate for Payer: United Healthcare Commercial |
$571.50
|
|
|
PLATE LOCKING AXSOS RECON 10 HOLE L120
|
Facility
|
OP
|
$635.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046738
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$285.75 |
| Max. Negotiated Rate |
$571.50 |
| Rate for Payer: Aetna of IA Commercial |
$571.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$571.50
|
| Rate for Payer: Aetna of IA Medicare |
$361.95
|
| Rate for Payer: Amerigroup Medicaid |
$366.27
|
| Rate for Payer: Amerigroup Medicare |
$288.61
|
| Rate for Payer: Cash Price |
$508.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$476.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$285.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$362.71
|
| Rate for Payer: Medical Associates Commercial |
$476.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$285.75
|
| Rate for Payer: Midlands Choice Commercial |
$444.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$368.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$328.61
|
| Rate for Payer: United Healthcare Commercial |
$571.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$374.65
|
|
|
PLATE LOCKING AXSOS RECON 4 HOLE L48
|
Facility
|
IP
|
$477.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$333.90 |
| Max. Negotiated Rate |
$429.30 |
| Rate for Payer: Aetna of IA Commercial |
$429.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$429.30
|
| Rate for Payer: Cash Price |
$381.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$357.75
|
| Rate for Payer: Medical Associates Commercial |
$357.75
|
| Rate for Payer: Midlands Choice Commercial |
$333.90
|
| Rate for Payer: United Healthcare Commercial |
$429.30
|
|
|
PLATE LOCKING AXSOS RECON 4 HOLE L48
|
Facility
|
OP
|
$477.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046735
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$214.65 |
| Max. Negotiated Rate |
$429.30 |
| Rate for Payer: Aetna of IA Commercial |
$429.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$429.30
|
| Rate for Payer: Aetna of IA Medicare |
$271.89
|
| Rate for Payer: Amerigroup Medicaid |
$275.13
|
| Rate for Payer: Amerigroup Medicare |
$216.80
|
| Rate for Payer: Cash Price |
$381.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$357.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$214.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$272.46
|
| Rate for Payer: Medical Associates Commercial |
$357.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$214.65
|
| Rate for Payer: Midlands Choice Commercial |
$333.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$276.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$246.85
|
| Rate for Payer: United Healthcare Commercial |
$429.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$281.43
|
|
|
PLATE LOCKING AXSOS RECON 6 HOLE L172
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$252.45 |
| Max. Negotiated Rate |
$504.90 |
| Rate for Payer: Aetna of IA Commercial |
$504.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$504.90
|
| Rate for Payer: Aetna of IA Medicare |
$319.77
|
| Rate for Payer: Amerigroup Medicaid |
$323.58
|
| Rate for Payer: Amerigroup Medicare |
$254.97
|
| Rate for Payer: Cash Price |
$448.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$420.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$252.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$320.44
|
| Rate for Payer: Medical Associates Commercial |
$420.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$252.45
|
| Rate for Payer: Midlands Choice Commercial |
$392.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$325.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$290.32
|
| Rate for Payer: United Healthcare Commercial |
$504.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$330.99
|
|
|
PLATE LOCKING AXSOS RECON 6 HOLE L172
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$392.70 |
| Max. Negotiated Rate |
$504.90 |
| Rate for Payer: Aetna of IA Commercial |
$504.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$504.90
|
| Rate for Payer: Cash Price |
$448.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$420.75
|
| Rate for Payer: Medical Associates Commercial |
$420.75
|
| Rate for Payer: Midlands Choice Commercial |
$392.70
|
| Rate for Payer: United Healthcare Commercial |
$504.90
|
|
|
PLATE LOCKING AXSOS RECON 8 HOLE L96
|
Facility
|
IP
|
$615.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046737
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.50 |
| Max. Negotiated Rate |
$553.50 |
| Rate for Payer: Aetna of IA Commercial |
$553.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$553.50
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$461.25
|
| Rate for Payer: Medical Associates Commercial |
$461.25
|
| Rate for Payer: Midlands Choice Commercial |
$430.50
|
| Rate for Payer: United Healthcare Commercial |
$553.50
|
|
|
PLATE LOCKING AXSOS RECON 8 HOLE L96
|
Facility
|
OP
|
$615.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046737
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$276.75 |
| Max. Negotiated Rate |
$553.50 |
| Rate for Payer: Aetna of IA Commercial |
$553.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$553.50
|
| Rate for Payer: Aetna of IA Medicare |
$350.55
|
| Rate for Payer: Amerigroup Medicaid |
$354.73
|
| Rate for Payer: Amerigroup Medicare |
$279.52
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$461.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$276.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$351.29
|
| Rate for Payer: Medical Associates Commercial |
$461.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$276.75
|
| Rate for Payer: Midlands Choice Commercial |
$430.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$356.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$318.26
|
| Rate for Payer: United Healthcare Commercial |
$553.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$362.85
|
|
|
PLATE LOCKING DELTOID AVULSION, SS, 5H
|
Facility
|
IP
|
$1,114.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047167
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$779.80 |
| Max. Negotiated Rate |
$1,002.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,002.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,002.60
|
| Rate for Payer: Cash Price |
$891.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$835.50
|
| Rate for Payer: Medical Associates Commercial |
$835.50
|
| Rate for Payer: Midlands Choice Commercial |
$779.80
|
| Rate for Payer: United Healthcare Commercial |
$1,002.60
|
|
|
PLATE LOCKING DELTOID AVULSION, SS, 5H
|
Facility
|
OP
|
$1,114.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047167
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.30 |
| Max. Negotiated Rate |
$1,002.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,002.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,002.60
|
| Rate for Payer: Aetna of IA Medicare |
$634.98
|
| Rate for Payer: Amerigroup Medicaid |
$642.56
|
| Rate for Payer: Amerigroup Medicare |
$506.31
|
| Rate for Payer: Cash Price |
$891.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$835.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$501.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$636.32
|
| Rate for Payer: Medical Associates Commercial |
$835.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$501.30
|
| Rate for Payer: Midlands Choice Commercial |
$779.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$645.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$576.50
|
| Rate for Payer: United Healthcare Commercial |
$1,002.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$657.26
|
|
|
PLATE LOCKING DELTOID AVULSION, SS, 7H
|
Facility
|
OP
|
$1,215.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047168
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$546.75 |
| Max. Negotiated Rate |
$1,093.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,093.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,093.50
|
| Rate for Payer: Aetna of IA Medicare |
$692.55
|
| Rate for Payer: Amerigroup Medicaid |
$700.81
|
| Rate for Payer: Amerigroup Medicare |
$552.22
|
| Rate for Payer: Cash Price |
$972.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$911.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$546.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$694.01
|
| Rate for Payer: Medical Associates Commercial |
$911.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$546.75
|
| Rate for Payer: Midlands Choice Commercial |
$850.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$704.21
|
| Rate for Payer: Partners Health Alliance Commercial |
$628.76
|
| Rate for Payer: United Healthcare Commercial |
$1,093.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$716.85
|
|
|
PLATE LOCKING DELTOID AVULSION, SS, 7H
|
Facility
|
IP
|
$1,215.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047168
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$850.50 |
| Max. Negotiated Rate |
$1,093.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,093.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,093.50
|
| Rate for Payer: Cash Price |
$972.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$911.25
|
| Rate for Payer: Medical Associates Commercial |
$911.25
|
| Rate for Payer: Midlands Choice Commercial |
$850.50
|
| Rate for Payer: United Healthcare Commercial |
$1,093.50
|
|
|
PLATE LOCKING DISTAL FIBULA, SS,LEFT, 4H
|
Facility
|
IP
|
$743.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$520.10 |
| Max. Negotiated Rate |
$668.70 |
| Rate for Payer: Aetna of IA Commercial |
$668.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$668.70
|
| Rate for Payer: Cash Price |
$594.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$557.25
|
| Rate for Payer: Medical Associates Commercial |
$557.25
|
| Rate for Payer: Midlands Choice Commercial |
$520.10
|
| Rate for Payer: United Healthcare Commercial |
$668.70
|
|
|
PLATE LOCKING DISTAL FIBULA, SS,LEFT, 4H
|
Facility
|
OP
|
$743.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047152
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$334.35 |
| Max. Negotiated Rate |
$668.70 |
| Rate for Payer: Aetna of IA Commercial |
$668.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$668.70
|
| Rate for Payer: Aetna of IA Medicare |
$423.51
|
| Rate for Payer: Amerigroup Medicaid |
$428.56
|
| Rate for Payer: Amerigroup Medicare |
$337.69
|
| Rate for Payer: Cash Price |
$594.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$557.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$334.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$424.40
|
| Rate for Payer: Medical Associates Commercial |
$557.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$334.35
|
| Rate for Payer: Midlands Choice Commercial |
$520.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$430.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$384.50
|
| Rate for Payer: United Healthcare Commercial |
$668.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$438.37
|
|
|
PLATE LOCKING DISTAL FIBULA, SS,LEFT, 5H
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047153
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$395.10 |
| Max. Negotiated Rate |
$790.20 |
| Rate for Payer: Aetna of IA Commercial |
$790.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$790.20
|
| Rate for Payer: Aetna of IA Medicare |
$500.46
|
| Rate for Payer: Amerigroup Medicaid |
$506.43
|
| Rate for Payer: Amerigroup Medicare |
$399.05
|
| Rate for Payer: Cash Price |
$702.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$658.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$395.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$501.51
|
| Rate for Payer: Medical Associates Commercial |
$658.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$395.10
|
| Rate for Payer: Midlands Choice Commercial |
$614.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$508.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$454.36
|
| Rate for Payer: United Healthcare Commercial |
$790.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$518.02
|
|
|
PLATE LOCKING DISTAL FIBULA, SS,LEFT, 5H
|
Facility
|
IP
|
$878.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047153
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.60 |
| Max. Negotiated Rate |
$790.20 |
| Rate for Payer: Aetna of IA Commercial |
$790.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$790.20
|
| Rate for Payer: Cash Price |
$702.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$658.50
|
| Rate for Payer: Medical Associates Commercial |
$658.50
|
| Rate for Payer: Midlands Choice Commercial |
$614.60
|
| Rate for Payer: United Healthcare Commercial |
$790.20
|
|
|
PLATE LOCKING DISTAL FIBULA, SS,LEFT, 6H
|
Facility
|
IP
|
$979.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047154
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$685.30 |
| Max. Negotiated Rate |
$881.10 |
| Rate for Payer: Aetna of IA Commercial |
$881.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$881.10
|
| Rate for Payer: Cash Price |
$783.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$734.25
|
| Rate for Payer: Medical Associates Commercial |
$734.25
|
| Rate for Payer: Midlands Choice Commercial |
$685.30
|
| Rate for Payer: United Healthcare Commercial |
$881.10
|
|
