|
sulfaSALAzine 500 mg Tab [VDMC]
|
Facility
|
OP
|
$1.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna of IA Commercial |
$1.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.54
|
| Rate for Payer: Aetna of IA Medicare |
$0.98
|
| Rate for Payer: Amerigroup Medicaid |
$0.99
|
| Rate for Payer: Amerigroup Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.29
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.98
|
| Rate for Payer: Medical Associates Commercial |
$1.29
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.77
|
| Rate for Payer: Midlands Choice Commercial |
$1.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.89
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.01
|
|
|
sulfaSALAzine 500 mg Tab [VDMC]
|
Facility
|
IP
|
$1.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna of IA Commercial |
$1.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.54
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.29
|
| Rate for Payer: Medical Associates Commercial |
$1.29
|
| Rate for Payer: Midlands Choice Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
|
|
SUMAtriptan 100 mg Tab [VDMC]
|
Facility
|
OP
|
$2.99
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| 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 |
$1.34
|
| 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 |
$1.34
|
| 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
|
|
|
SUMAtriptan 100 mg Tab [VDMC]
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423072
|
|
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
|
|
|
SUMAtriptan 6 mg/0.5 mL SubQ SDV [VDMC]
|
Facility
|
OP
|
$33.70
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
10423141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.17 |
| Max. Negotiated Rate |
$30.33 |
| Rate for Payer: Aetna of IA Commercial |
$30.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.33
|
| Rate for Payer: Aetna of IA Medicare |
$19.21
|
| Rate for Payer: Amerigroup Medicaid |
$19.44
|
| Rate for Payer: Amerigroup Medicare |
$15.32
|
| Rate for Payer: Cash Price |
$26.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.17
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.25
|
| Rate for Payer: Medical Associates Commercial |
$25.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.17
|
| Rate for Payer: Midlands Choice Commercial |
$23.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.44
|
| Rate for Payer: United Healthcare Commercial |
$30.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.89
|
|
|
SUMAtriptan 6 mg/0.5 mL SubQ SDV [VDMC]
|
Facility
|
IP
|
$33.70
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
10423141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.59 |
| Max. Negotiated Rate |
$30.33 |
| Rate for Payer: Aetna of IA Commercial |
$30.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.33
|
| Rate for Payer: Cash Price |
$26.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.28
|
| Rate for Payer: Medical Associates Commercial |
$25.28
|
| Rate for Payer: Midlands Choice Commercial |
$23.59
|
| Rate for Payer: United Healthcare Commercial |
$30.33
|
|
|
SUPPLIES FOR WOUND CARE NON SELECTIVE
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
8013710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$168.30 |
| Max. Negotiated Rate |
$336.60 |
| Rate for Payer: Aetna of IA Commercial |
$336.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.60
|
| Rate for Payer: Aetna of IA Medicare |
$213.18
|
| Rate for Payer: Amerigroup Medicaid |
$215.72
|
| Rate for Payer: Amerigroup Medicare |
$169.98
|
| Rate for Payer: Cash Price |
$299.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$168.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$213.63
|
| Rate for Payer: Medical Associates Commercial |
$280.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$168.30
|
| Rate for Payer: Midlands Choice Commercial |
$261.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$216.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$193.54
|
| Rate for Payer: United Healthcare Commercial |
$336.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$220.66
|
|
|
SUPPLIES FOR WOUND CARE NON SELECTIVE
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
8013710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.80 |
| Max. Negotiated Rate |
$336.60 |
| Rate for Payer: Aetna of IA Commercial |
$336.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.60
|
| Rate for Payer: Cash Price |
$299.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.50
|
| Rate for Payer: Medical Associates Commercial |
$280.50
|
| Rate for Payer: Midlands Choice Commercial |
$261.80
|
| Rate for Payer: United Healthcare Commercial |
$336.60
|
|
|
SURETAPE 2-0
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8767795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
|
|
SURETAPE 2-0
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8767795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Aetna of IA Medicare |
$59.28
|
| Rate for Payer: Amerigroup Medicaid |
$59.99
|
| Rate for Payer: Amerigroup Medicare |
$47.27
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$46.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.40
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$46.80
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$53.82
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.36
|
|
|
SURGIMESH HERNIA BARRIER MESH VENRAL
|
Facility
|
IP
|
$2,988.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
8046321
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,091.60 |
| Max. Negotiated Rate |
$2,689.20 |
| Rate for Payer: Aetna of IA Commercial |
$2,689.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,689.20
|
| Rate for Payer: Cash Price |
$2,390.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,241.00
|
| Rate for Payer: Medical Associates Commercial |
$2,241.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,091.60
|
| Rate for Payer: United Healthcare Commercial |
$2,689.20
|
|
|
SURGIMESH HERNIA BARRIER MESH VENRAL
|
Facility
|
OP
|
$2,988.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
8046321
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,344.60 |
| Max. Negotiated Rate |
$2,689.20 |
| Rate for Payer: Aetna of IA Commercial |
$2,689.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,689.20
|
| Rate for Payer: Aetna of IA Medicare |
$1,703.16
|
| Rate for Payer: Amerigroup Medicaid |
$1,723.48
|
| Rate for Payer: Amerigroup Medicare |
$1,358.05
|
| Rate for Payer: Cash Price |
$2,390.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,241.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,344.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,706.75
|
| Rate for Payer: Medical Associates Commercial |
$2,241.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,344.60
|
| Rate for Payer: Midlands Choice Commercial |
$2,091.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,731.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,546.29
|
| Rate for Payer: United Healthcare Commercial |
$2,689.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,762.92
|
|
|
SURGIMESH OPEN/LAP INGUINAL 7 CM
|
Facility
|
OP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
8026545
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$648.00 |
| Max. Negotiated Rate |
$1,296.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,296.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,296.00
|
| Rate for Payer: Aetna of IA Medicare |
$820.80
|
| Rate for Payer: Amerigroup Medicaid |
$830.59
|
| Rate for Payer: Amerigroup Medicare |
$654.48
|
| Rate for Payer: Cash Price |
$1,152.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,080.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$648.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$822.53
|
| Rate for Payer: Medical Associates Commercial |
$1,080.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$648.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,008.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$745.20
|
| Rate for Payer: United Healthcare Commercial |
$1,296.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.60
|
|
|
SURGIMESH OPEN/LAP INGUINAL 7 CM
|
Facility
|
IP
|
$1,440.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
8026545
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,008.00 |
| Max. Negotiated Rate |
$1,296.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,296.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,296.00
|
| Rate for Payer: Cash Price |
$1,152.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,080.00
|
| Rate for Payer: Medical Associates Commercial |
$1,080.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,008.00
|
| Rate for Payer: United Healthcare Commercial |
$1,296.00
|
|
|
SURGITIE LIGATING LOOP
|
Facility
|
IP
|
$1,104.00
|
|
| Hospital Charge Code |
8046978
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$772.80 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Aetna of IA Commercial |
$993.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$993.60
|
| Rate for Payer: Cash Price |
$883.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$828.00
|
| Rate for Payer: Medical Associates Commercial |
$828.00
|
| Rate for Payer: Midlands Choice Commercial |
$772.80
|
| Rate for Payer: United Healthcare Commercial |
$993.60
|
|
|
SURGITIE LIGATING LOOP
|
Facility
|
OP
|
$1,104.00
|
|
| Hospital Charge Code |
8046978
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$496.80 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Aetna of IA Commercial |
$993.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$993.60
|
| Rate for Payer: Aetna of IA Medicare |
$629.28
|
| Rate for Payer: Amerigroup Medicaid |
$636.79
|
| Rate for Payer: Amerigroup Medicare |
$501.77
|
| Rate for Payer: Cash Price |
$883.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$828.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$496.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$630.60
|
| Rate for Payer: Medical Associates Commercial |
$828.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$496.80
|
| Rate for Payer: Midlands Choice Commercial |
$772.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$639.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$571.32
|
| Rate for Payer: United Healthcare Commercial |
$993.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$651.36
|
|
|
SURG TX MISSED ABORT; 2ND TRIMESTR
|
Professional
|
Both
|
$1,283.00
|
|
|
Service Code
|
CPT 59821
|
| Hospital Charge Code |
8068908
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$303.85 |
| Max. Negotiated Rate |
$974.60 |
| Rate for Payer: Amerigroup Medicaid |
$306.83
|
| Rate for Payer: Cash Price |
$1,026.40
|
| Rate for Payer: Cash Price |
$1,026.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$303.85
|
| Rate for Payer: Medical Associates Commercial |
$962.25
|
| Rate for Payer: Midlands Choice Commercial |
$898.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$305.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$962.25
|
| Rate for Payer: United Healthcare Commercial |
$607.06
|
| Rate for Payer: Wellmark IA HMO WHPI |
$828.40
|
| Rate for Payer: Wellmark IA PPO |
$974.60
|
|
|
SUTURE ANCH, BIO-COMPOSITE P-LCK 2.4X11.3
|
Facility
|
IP
|
$1,030.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8771306
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$721.00 |
| Max. Negotiated Rate |
$927.00 |
| Rate for Payer: Aetna of IA Commercial |
$927.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$927.00
|
| Rate for Payer: Cash Price |
$824.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$772.50
|
| Rate for Payer: Medical Associates Commercial |
$772.50
|
| Rate for Payer: Midlands Choice Commercial |
$721.00
|
| Rate for Payer: United Healthcare Commercial |
$927.00
|
|
|
SUTURE ANCH, BIO-COMPOSITE P-LCK 2.4X11.3
|
Facility
|
OP
|
$1,030.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8771306
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$463.50 |
| Max. Negotiated Rate |
$927.00 |
| Rate for Payer: Aetna of IA Commercial |
$927.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$927.00
|
| Rate for Payer: Aetna of IA Medicare |
$587.10
|
| Rate for Payer: Amerigroup Medicaid |
$594.10
|
| Rate for Payer: Amerigroup Medicare |
$468.14
|
| Rate for Payer: Cash Price |
$824.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$772.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$463.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$588.34
|
| Rate for Payer: Medical Associates Commercial |
$772.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$463.50
|
| Rate for Payer: Midlands Choice Commercial |
$721.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$596.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$533.02
|
| Rate for Payer: United Healthcare Commercial |
$927.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$607.70
|
|
|
SUTURE ANCHOR BIOCOMPOSITE SWIVELOCK 4.75 X 19.1
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8026420
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna of IA Commercial |
$648.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$648.00
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$540.00
|
| Rate for Payer: Medical Associates Commercial |
$540.00
|
| Rate for Payer: Midlands Choice Commercial |
$504.00
|
| Rate for Payer: United Healthcare Commercial |
$648.00
|
|
|
SUTURE ANCHOR BIOCOMPOSITE SWIVELOCK 4.75 X 19.1
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8026420
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$324.00 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna of IA Commercial |
$648.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$648.00
|
| Rate for Payer: Aetna of IA Medicare |
$410.40
|
| Rate for Payer: Amerigroup Medicaid |
$415.30
|
| Rate for Payer: Amerigroup Medicare |
$327.24
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$540.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$324.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$411.26
|
| Rate for Payer: Medical Associates Commercial |
$540.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$324.00
|
| Rate for Payer: Midlands Choice Commercial |
$504.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$417.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$372.60
|
| Rate for Payer: United Healthcare Commercial |
$648.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$424.80
|
|
|
SUTURE ANCHOR BIOCOMPOSITE SWIVELOCK 5.5 X 24.5
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8025946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$324.00 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna of IA Commercial |
$648.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$648.00
|
| Rate for Payer: Aetna of IA Medicare |
$410.40
|
| Rate for Payer: Amerigroup Medicaid |
$415.30
|
| Rate for Payer: Amerigroup Medicare |
$327.24
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$540.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$324.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$411.26
|
| Rate for Payer: Medical Associates Commercial |
$540.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$324.00
|
| Rate for Payer: Midlands Choice Commercial |
$504.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$417.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$372.60
|
| Rate for Payer: United Healthcare Commercial |
$648.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$424.80
|
|
|
SUTURE ANCHOR BIOCOMPOSITE SWIVELOCK 5.5 X 24.5
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8025946
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna of IA Commercial |
$648.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$648.00
|
| Rate for Payer: Cash Price |
$576.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$540.00
|
| Rate for Payer: Medical Associates Commercial |
$540.00
|
| Rate for Payer: Midlands Choice Commercial |
$504.00
|
| Rate for Payer: United Healthcare Commercial |
$648.00
|
|
|
SUTURE ANCHOR MINIBIO SUTURETAK 2.4X8.5M
|
Facility
|
OP
|
$585.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8026400
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$526.50 |
| Rate for Payer: Aetna of IA Commercial |
$526.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$526.50
|
| Rate for Payer: Aetna of IA Medicare |
$333.45
|
| Rate for Payer: Amerigroup Medicaid |
$337.43
|
| Rate for Payer: Amerigroup Medicare |
$265.88
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$438.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$263.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$334.15
|
| Rate for Payer: Medical Associates Commercial |
$438.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$263.25
|
| Rate for Payer: Midlands Choice Commercial |
$409.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$339.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$302.74
|
| Rate for Payer: United Healthcare Commercial |
$526.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$345.15
|
|
|
SUTURE ANCHOR MINIBIO SUTURETAK 2.4X8.5M
|
Facility
|
IP
|
$585.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8026400
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$526.50 |
| Rate for Payer: Aetna of IA Commercial |
$526.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$526.50
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$438.75
|
| Rate for Payer: Medical Associates Commercial |
$438.75
|
| Rate for Payer: Midlands Choice Commercial |
$409.50
|
| Rate for Payer: United Healthcare Commercial |
$526.50
|
|
