|
SINGLE PULSE OXIMETRY
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
CPT 94760
|
| Hospital Charge Code |
5338940
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna of IA Commercial |
$9.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.00
|
| Rate for Payer: Cash Price |
$8.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.50
|
| Rate for Payer: Medical Associates Commercial |
$7.50
|
| Rate for Payer: Midlands Choice Commercial |
$7.00
|
| Rate for Payer: United Healthcare Commercial |
$9.00
|
|
|
sitaGLIPtin 50 mg oral tablet [VDMC]
|
Facility
|
IP
|
$58.53
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421132
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.97 |
| Max. Negotiated Rate |
$52.68 |
| Rate for Payer: Aetna of IA Commercial |
$52.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.68
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.90
|
| Rate for Payer: Medical Associates Commercial |
$43.90
|
| Rate for Payer: Midlands Choice Commercial |
$40.97
|
| Rate for Payer: United Healthcare Commercial |
$52.68
|
|
|
sitaGLIPtin 50 mg oral tablet [VDMC]
|
Facility
|
OP
|
$58.53
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421132
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.34 |
| Max. Negotiated Rate |
$52.68 |
| Rate for Payer: Aetna of IA Commercial |
$52.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.68
|
| Rate for Payer: Aetna of IA Medicare |
$33.36
|
| Rate for Payer: Amerigroup Medicaid |
$33.76
|
| Rate for Payer: Amerigroup Medicare |
$26.60
|
| Rate for Payer: Cash Price |
$46.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.43
|
| Rate for Payer: Medical Associates Commercial |
$43.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.34
|
| Rate for Payer: Midlands Choice Commercial |
$40.97
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.29
|
| Rate for Payer: United Healthcare Commercial |
$52.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.53
|
|
|
Sjogren's A Antibody DMCL
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
8037800
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$122.40 |
| Rate for Payer: Aetna of IA Commercial |
$122.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$122.40
|
| Rate for Payer: Aetna of IA Medicare |
$77.52
|
| Rate for Payer: Amerigroup Medicaid |
$78.44
|
| Rate for Payer: Amerigroup Medicare |
$61.81
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$102.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$61.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$77.68
|
| Rate for Payer: Medical Associates Commercial |
$102.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$61.20
|
| Rate for Payer: Midlands Choice Commercial |
$95.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$78.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$70.38
|
| Rate for Payer: United Healthcare Commercial |
$122.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$80.24
|
|
|
Sjogren's A Antibody DMCL
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
8037800
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$122.40 |
| Rate for Payer: Aetna of IA Commercial |
$122.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$122.40
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$102.00
|
| Rate for Payer: Medical Associates Commercial |
$102.00
|
| Rate for Payer: Midlands Choice Commercial |
$95.20
|
| Rate for Payer: United Healthcare Commercial |
$122.40
|
|
|
Sjogren's B Antibody DMCL
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
8037801
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$122.40 |
| Rate for Payer: Aetna of IA Commercial |
$122.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$122.40
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$102.00
|
| Rate for Payer: Medical Associates Commercial |
$102.00
|
| Rate for Payer: Midlands Choice Commercial |
$95.20
|
| Rate for Payer: United Healthcare Commercial |
$122.40
|
|
|
Sjogren's B Antibody DMCL
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
8037801
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$122.40 |
| Rate for Payer: Aetna of IA Commercial |
$122.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$122.40
|
| Rate for Payer: Aetna of IA Medicare |
$77.52
|
| Rate for Payer: Amerigroup Medicaid |
$78.44
|
| Rate for Payer: Amerigroup Medicare |
$61.81
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$102.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$61.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$77.68
|
| Rate for Payer: Medical Associates Commercial |
$102.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$61.20
|
| Rate for Payer: Midlands Choice Commercial |
$95.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$78.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$70.38
|
| Rate for Payer: United Healthcare Commercial |
$122.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$80.24
|
|
|
SLEEP STUDY ATTENDED
|
Facility
|
IP
|
$3,126.00
|
|
|
Service Code
|
CPT 95810
|
| Hospital Charge Code |
5338942
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$2,188.20 |
| Max. Negotiated Rate |
$2,813.40 |
| Rate for Payer: Aetna of IA Commercial |
$2,813.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,813.40
|
| Rate for Payer: Cash Price |
$2,500.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,344.50
|
| Rate for Payer: Medical Associates Commercial |
$2,344.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,188.20
|
| Rate for Payer: United Healthcare Commercial |
$2,813.40
|
|
|
SLEEP STUDY ATTENDED
|
Facility
|
OP
|
$3,126.00
|
|
|
Service Code
|
CPT 95810
|
| Hospital Charge Code |
5338942
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$1,406.70 |
| Max. Negotiated Rate |
$2,813.40 |
| Rate for Payer: Aetna of IA Commercial |
$2,813.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,813.40
|
| Rate for Payer: Aetna of IA Medicare |
$1,781.82
|
| Rate for Payer: Amerigroup Medicaid |
$1,803.08
|
| Rate for Payer: Amerigroup Medicare |
$1,420.77
|
| Rate for Payer: Cash Price |
$2,500.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,344.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,406.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,785.57
|
| Rate for Payer: Medical Associates Commercial |
$2,344.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,406.70
|
| Rate for Payer: Midlands Choice Commercial |
$2,188.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,811.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,617.70
|
| Rate for Payer: United Healthcare Commercial |
$2,813.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,844.34
|
|
|
SLEEP STUDY/CPAP TRIAL
|
Facility
|
OP
|
$3,376.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
5338943
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$1,519.20 |
| Max. Negotiated Rate |
$3,038.40 |
| Rate for Payer: Aetna of IA Commercial |
$3,038.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,038.40
|
| Rate for Payer: Aetna of IA Medicare |
$1,924.32
|
| Rate for Payer: Amerigroup Medicaid |
$1,947.28
|
| Rate for Payer: Amerigroup Medicare |
$1,534.39
|
| Rate for Payer: Cash Price |
$2,700.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,532.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,519.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,928.37
|
| Rate for Payer: Medical Associates Commercial |
$2,532.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,519.20
|
| Rate for Payer: Midlands Choice Commercial |
$2,363.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,956.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,747.08
|
| Rate for Payer: United Healthcare Commercial |
$3,038.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,991.84
|
|
|
SLEEP STUDY/CPAP TRIAL
|
Facility
|
IP
|
$3,376.00
|
|
|
Service Code
|
CPT 95811
|
| Hospital Charge Code |
5338943
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$2,363.20 |
| Max. Negotiated Rate |
$3,038.40 |
| Rate for Payer: Aetna of IA Commercial |
$3,038.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,038.40
|
| Rate for Payer: Cash Price |
$2,700.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,532.00
|
| Rate for Payer: Medical Associates Commercial |
$2,532.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,363.20
|
| Rate for Payer: United Healthcare Commercial |
$3,038.40
|
|
|
SLEEP STUDY MSLT
|
Facility
|
OP
|
$3,126.00
|
|
|
Service Code
|
CPT 95805
|
| Hospital Charge Code |
6608799
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$1,406.70 |
| Max. Negotiated Rate |
$2,813.40 |
| Rate for Payer: Aetna of IA Commercial |
$2,813.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,813.40
|
| Rate for Payer: Aetna of IA Medicare |
$1,781.82
|
| Rate for Payer: Amerigroup Medicaid |
$1,803.08
|
| Rate for Payer: Amerigroup Medicare |
$1,420.77
|
| Rate for Payer: Cash Price |
$2,500.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,344.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,406.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,785.57
|
| Rate for Payer: Medical Associates Commercial |
$2,344.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,406.70
|
| Rate for Payer: Midlands Choice Commercial |
$2,188.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,811.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,617.70
|
| Rate for Payer: United Healthcare Commercial |
$2,813.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,844.34
|
|
|
SLEEP STUDY MSLT
|
Facility
|
IP
|
$3,126.00
|
|
|
Service Code
|
CPT 95805
|
| Hospital Charge Code |
6608799
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$2,188.20 |
| Max. Negotiated Rate |
$2,813.40 |
| Rate for Payer: Aetna of IA Commercial |
$2,813.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,813.40
|
| Rate for Payer: Cash Price |
$2,500.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,344.50
|
| Rate for Payer: Medical Associates Commercial |
$2,344.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,188.20
|
| Rate for Payer: United Healthcare Commercial |
$2,813.40
|
|
|
SLITTING OF PREPUCE
|
Facility
|
OP
|
$1,194.00
|
|
|
Service Code
|
CPT 54001
|
| Hospital Charge Code |
7982916
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$537.30 |
| Max. Negotiated Rate |
$1,074.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,074.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,074.60
|
| Rate for Payer: Aetna of IA Medicare |
$680.58
|
| Rate for Payer: Amerigroup Medicaid |
$688.70
|
| Rate for Payer: Amerigroup Medicare |
$542.67
|
| Rate for Payer: Cash Price |
$955.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$895.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$537.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$682.01
|
| Rate for Payer: Medical Associates Commercial |
$895.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$537.30
|
| Rate for Payer: Midlands Choice Commercial |
$835.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$692.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$617.89
|
| Rate for Payer: United Healthcare Commercial |
$1,074.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$704.46
|
|
|
SLITTING OF PREPUCE
|
Facility
|
IP
|
$1,194.00
|
|
|
Service Code
|
CPT 54001
|
| Hospital Charge Code |
7982916
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$835.80 |
| Max. Negotiated Rate |
$1,074.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,074.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,074.60
|
| Rate for Payer: Cash Price |
$955.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$895.50
|
| Rate for Payer: Medical Associates Commercial |
$895.50
|
| Rate for Payer: Midlands Choice Commercial |
$835.80
|
| Rate for Payer: United Healthcare Commercial |
$1,074.60
|
|
|
SLP Eval of Speech Sound Prod Units
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 92522
|
| Hospital Charge Code |
5528784
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
|
|
SLP Eval of Speech Sound Prod Units
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 92522
|
| Hospital Charge Code |
5528784
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$103.50 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Aetna of IA Medicare |
$131.10
|
| Rate for Payer: Amerigroup Medicaid |
$132.66
|
| Rate for Payer: Amerigroup Medicare |
$104.53
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$103.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$131.38
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$103.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$133.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$119.03
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$135.70
|
|
|
SMALL VLC PLATE RIGHT
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8700302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$810.00 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,620.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,620.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,026.00
|
| Rate for Payer: Amerigroup Medicaid |
$1,038.24
|
| Rate for Payer: Amerigroup Medicare |
$818.10
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,350.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$810.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,028.16
|
| Rate for Payer: Medical Associates Commercial |
$1,350.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$810.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,260.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,043.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$931.50
|
| Rate for Payer: United Healthcare Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,062.00
|
|
|
SMALL VLC PLATE RIGHT
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8700302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,260.00 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,620.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,620.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,350.00
|
| Rate for Payer: Medical Associates Commercial |
$1,350.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,260.00
|
| Rate for Payer: United Healthcare Commercial |
$1,620.00
|
|
|
Smooth Muscle Antibody DMCL
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
8037802
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$51.75 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of IA Commercial |
$103.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.50
|
| Rate for Payer: Aetna of IA Medicare |
$65.55
|
| Rate for Payer: Amerigroup Medicaid |
$66.33
|
| Rate for Payer: Amerigroup Medicare |
$52.27
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.69
|
| Rate for Payer: Medical Associates Commercial |
$86.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.75
|
| Rate for Payer: Midlands Choice Commercial |
$80.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$59.51
|
| Rate for Payer: United Healthcare Commercial |
$103.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.85
|
|
|
Smooth Muscle Antibody DMCL
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
8037802
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of IA Commercial |
$103.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.50
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.25
|
| Rate for Payer: Medical Associates Commercial |
$86.25
|
| Rate for Payer: Midlands Choice Commercial |
$80.50
|
| Rate for Payer: United Healthcare Commercial |
$103.50
|
|
|
SNIPER STAPLE 18MMX18MMX18MM
|
Facility
|
OP
|
$1,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8713571
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$769.50 |
| Max. Negotiated Rate |
$1,539.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,539.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,539.00
|
| Rate for Payer: Aetna of IA Medicare |
$974.70
|
| Rate for Payer: Amerigroup Medicaid |
$986.33
|
| Rate for Payer: Amerigroup Medicare |
$777.20
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,282.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$769.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$976.75
|
| Rate for Payer: Medical Associates Commercial |
$1,282.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$769.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,197.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$991.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$884.92
|
| Rate for Payer: United Healthcare Commercial |
$1,539.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,008.90
|
|
|
SNIPER STAPLE 18MMX18MMX18MM
|
Facility
|
IP
|
$1,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8713571
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,197.00 |
| Max. Negotiated Rate |
$1,539.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,539.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,539.00
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,282.50
|
| Rate for Payer: Medical Associates Commercial |
$1,282.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,197.00
|
| Rate for Payer: United Healthcare Commercial |
$1,539.00
|
|
|
SNIPER STAPLE IMPLANT 10X10X10
|
Facility
|
OP
|
$2,520.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8734824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,134.00 |
| Max. Negotiated Rate |
$2,268.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,268.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,268.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,436.40
|
| Rate for Payer: Amerigroup Medicaid |
$1,453.54
|
| Rate for Payer: Amerigroup Medicare |
$1,145.34
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,890.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,134.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,439.42
|
| Rate for Payer: Medical Associates Commercial |
$1,890.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,134.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,764.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,460.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,304.10
|
| Rate for Payer: United Healthcare Commercial |
$2,268.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,486.80
|
|
|
SNIPER STAPLE IMPLANT 10X10X10
|
Facility
|
IP
|
$2,520.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8734824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,764.00 |
| Max. Negotiated Rate |
$2,268.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,268.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,268.00
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,890.00
|
| Rate for Payer: Medical Associates Commercial |
$1,890.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,764.00
|
| Rate for Payer: United Healthcare Commercial |
$2,268.00
|
|
