|
darbepoetin alfa 100 mcg/0.5ml PFS
|
Facility
OP
|
$798.23
|
|
|
Service Code
|
CPT J0881
|
| Hospital Charge Code |
43700377
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$398.96 |
| Max. Negotiated Rate |
$718.41 |
| Rate for Payer: Aetna of IA Commercial |
$718.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$718.41
|
| Rate for Payer: Aetna of IA Medicare |
$454.99
|
| Rate for Payer: Amerigroup Medicaid |
$402.87
|
| Rate for Payer: Amerigroup Medicare |
$403.11
|
| Rate for Payer: Cash Price |
$638.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$598.67
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$399.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$398.96
|
| Rate for Payer: Medical Associates Commercial |
$598.67
|
| Rate for Payer: Medical Associates Managed Medicare |
$399.12
|
| Rate for Payer: Midlands Choice Commercial |
$558.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$405.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$598.67
|
| Rate for Payer: United Healthcare Commercial |
$718.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$470.96
|
|
|
darbepoetin alfa 200 mcg/0.4 mL SDV Inj
|
Facility
IP
|
$3,084.66
|
|
|
Service Code
|
CPT J0881
|
| Hospital Charge Code |
43708918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,159.26 |
| Max. Negotiated Rate |
$2,776.19 |
| Rate for Payer: Aetna of IA Commercial |
$2,776.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,776.19
|
| Rate for Payer: Cash Price |
$2,467.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,313.50
|
| Rate for Payer: Medical Associates Commercial |
$2,313.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,159.26
|
| Rate for Payer: United Healthcare Commercial |
$2,776.19
|
|
|
darbepoetin alfa 200 mcg/0.4 mL SDV Inj
|
Facility
OP
|
$3,084.66
|
|
|
Service Code
|
CPT J0881
|
| Hospital Charge Code |
43708918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,541.71 |
| Max. Negotiated Rate |
$2,776.19 |
| Rate for Payer: Aetna of IA Commercial |
$2,776.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,776.19
|
| Rate for Payer: Aetna of IA Medicare |
$1,758.26
|
| Rate for Payer: Amerigroup Medicaid |
$1,556.83
|
| Rate for Payer: Amerigroup Medicare |
$1,557.75
|
| Rate for Payer: Cash Price |
$2,467.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,313.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,542.33
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,541.71
|
| Rate for Payer: Medical Associates Commercial |
$2,313.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,542.33
|
| Rate for Payer: Midlands Choice Commercial |
$2,159.26
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,565.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,313.50
|
| Rate for Payer: United Healthcare Commercial |
$2,776.19
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,819.95
|
|
|
darbepoetin alfa 200 mcg/mL 1 ml SDV
|
Facility
IP
|
$2,968.14
|
|
|
Service Code
|
CPT J0881
|
| Hospital Charge Code |
43700497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,077.70 |
| Max. Negotiated Rate |
$2,671.33 |
| Rate for Payer: Aetna of IA Commercial |
$2,671.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,671.33
|
| Rate for Payer: Cash Price |
$2,374.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,226.10
|
| Rate for Payer: Medical Associates Commercial |
$2,226.10
|
| Rate for Payer: Midlands Choice Commercial |
$2,077.70
|
| Rate for Payer: United Healthcare Commercial |
$2,671.33
|
|
|
darbepoetin alfa 200 mcg/mL 1 ml SDV
|
Facility
OP
|
$2,968.14
|
|
|
Service Code
|
CPT J0881
|
| Hospital Charge Code |
43700497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,483.48 |
| Max. Negotiated Rate |
$2,671.33 |
| Rate for Payer: Aetna of IA Commercial |
$2,671.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,671.33
|
| Rate for Payer: Aetna of IA Medicare |
$1,691.84
|
| Rate for Payer: Amerigroup Medicaid |
$1,498.02
|
| Rate for Payer: Amerigroup Medicare |
$1,498.91
|
| Rate for Payer: Cash Price |
$2,374.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,226.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,484.07
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,483.48
|
| Rate for Payer: Medical Associates Commercial |
$2,226.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,484.07
|
| Rate for Payer: Midlands Choice Commercial |
$2,077.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,506.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,226.10
|
| Rate for Payer: United Healthcare Commercial |
$2,671.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,751.20
|
|
|
darbepoetin alfa 300 mcg/0.6 mL SDS
|
Facility
IP
|
$2,194.68
|
|
|
Service Code
|
CPT J0881
|
| Hospital Charge Code |
43700499
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,536.28 |
| Max. Negotiated Rate |
$1,975.21 |
| Rate for Payer: Aetna of IA Commercial |
$1,975.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,975.21
|
| Rate for Payer: Cash Price |
$1,755.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,646.01
|
| Rate for Payer: Medical Associates Commercial |
$1,646.01
|
| Rate for Payer: Midlands Choice Commercial |
$1,536.28
|
| Rate for Payer: United Healthcare Commercial |
$1,975.21
|
|
|
darbepoetin alfa 300 mcg/0.6 mL SDS
|
Facility
OP
|
$2,194.68
|
|
|
Service Code
|
CPT J0881
|
| Hospital Charge Code |
43700499
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,096.90 |
| Max. Negotiated Rate |
$1,975.21 |
| Rate for Payer: Aetna of IA Commercial |
$1,975.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,975.21
|
| Rate for Payer: Aetna of IA Medicare |
$1,250.97
|
| Rate for Payer: Amerigroup Medicaid |
$1,107.65
|
| Rate for Payer: Amerigroup Medicare |
$1,108.31
|
| Rate for Payer: Cash Price |
$1,755.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,646.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,097.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,096.90
|
| Rate for Payer: Medical Associates Commercial |
$1,646.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,097.34
|
| Rate for Payer: Midlands Choice Commercial |
$1,536.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,113.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,646.01
|
| Rate for Payer: United Healthcare Commercial |
$1,975.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,294.86
|
|
|
DAT POLY TUBE
|
Facility
OP
|
$58.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
7912827
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$28.99 |
| Max. Negotiated Rate |
$107.07 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Aetna of IA Medicare |
$33.06
|
| Rate for Payer: Amerigroup Medicaid |
$29.27
|
| Rate for Payer: Amerigroup Medicare |
$29.29
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.99
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.00
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$43.50
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.22
|
| Rate for Payer: Wellmark IA HMO |
$97.34
|
| Rate for Payer: Wellmark IA PPO |
$107.07
|
|
|
DAT POLY TUBE
|
Facility
IP
|
$58.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
7912827
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
|
|
DBL LOADED 4.75MM BIO-COM SWVLK
|
Facility
OP
|
$1,073.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8760621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.29 |
| Max. Negotiated Rate |
$965.70 |
| Rate for Payer: Aetna of IA Commercial |
$965.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$965.70
|
| Rate for Payer: Aetna of IA Medicare |
$611.61
|
| Rate for Payer: Amerigroup Medicaid |
$541.54
|
| Rate for Payer: Amerigroup Medicare |
$541.86
|
| Rate for Payer: Cash Price |
$858.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$804.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$536.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$536.29
|
| Rate for Payer: Medical Associates Commercial |
$804.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$536.50
|
| Rate for Payer: Midlands Choice Commercial |
$751.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$544.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$804.75
|
| Rate for Payer: United Healthcare Commercial |
$965.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$633.07
|
|
|
DBL LOADED 4.75MM BIO-COM SWVLK
|
Facility
IP
|
$1,073.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8760621
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$751.10 |
| Max. Negotiated Rate |
$965.70 |
| Rate for Payer: Aetna of IA Commercial |
$965.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$965.70
|
| Rate for Payer: Cash Price |
$858.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$804.75
|
| Rate for Payer: Medical Associates Commercial |
$804.75
|
| Rate for Payer: Midlands Choice Commercial |
$751.10
|
| Rate for Payer: United Healthcare Commercial |
$965.70
|
|
|
D&C, Conization, Laparoscopy and Tubal Interruption With CC/MCC
|
Facility
IP
|
$9,226.28
|
|
|
Service Code
|
MS-DRG 744
|
| Hospital Charge Code |
505
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$9,226.28 |
| Rate for Payer: Amerigroup Medicaid |
$9,181.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9,092.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9,226.28
|
|
|
D&C, Conization, Laparoscopy and Tubal Interruption Without CC/MCC
|
Facility
IP
|
$9,226.28
|
|
|
Service Code
|
MS-DRG 745
|
| Hospital Charge Code |
506
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$9,226.28 |
| Rate for Payer: Amerigroup Medicaid |
$9,181.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9,092.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9,226.28
|
|
|
DDIMER
|
Facility
IP
|
$77.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
633718
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$69.30 |
| Rate for Payer: Aetna of IA Commercial |
$69.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.30
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.75
|
| Rate for Payer: Medical Associates Commercial |
$57.75
|
| Rate for Payer: Midlands Choice Commercial |
$53.90
|
| Rate for Payer: United Healthcare Commercial |
$69.30
|
|
|
DDIMER
|
Facility
IP
|
$77.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
8057341
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$69.30 |
| Rate for Payer: Aetna of IA Commercial |
$69.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.30
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.75
|
| Rate for Payer: Medical Associates Commercial |
$57.75
|
| Rate for Payer: Midlands Choice Commercial |
$53.90
|
| Rate for Payer: United Healthcare Commercial |
$69.30
|
|
|
DDIMER
|
Facility
OP
|
$77.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
633718
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$69.30 |
| Rate for Payer: Aetna of IA Commercial |
$69.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.30
|
| Rate for Payer: Aetna of IA Medicare |
$43.89
|
| Rate for Payer: Amerigroup Medicaid |
$38.86
|
| Rate for Payer: Amerigroup Medicare |
$38.88
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$38.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.48
|
| Rate for Payer: Medical Associates Commercial |
$57.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$38.50
|
| Rate for Payer: Midlands Choice Commercial |
$53.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$39.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.75
|
| Rate for Payer: United Healthcare Commercial |
$69.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$45.43
|
| Rate for Payer: Wellmark IA HMO |
$24.18
|
| Rate for Payer: Wellmark IA PPO |
$26.60
|
|
|
DDIMER
|
Facility
OP
|
$77.00
|
|
|
Service Code
|
CPT 85379
|
| Hospital Charge Code |
8057341
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$69.30 |
| Rate for Payer: Aetna of IA Commercial |
$69.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.30
|
| Rate for Payer: Aetna of IA Medicare |
$43.89
|
| Rate for Payer: Amerigroup Medicaid |
$38.86
|
| Rate for Payer: Amerigroup Medicare |
$38.88
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$38.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.48
|
| Rate for Payer: Medical Associates Commercial |
$57.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$38.50
|
| Rate for Payer: Midlands Choice Commercial |
$53.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$39.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.75
|
| Rate for Payer: United Healthcare Commercial |
$69.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$45.43
|
| Rate for Payer: Wellmark IA HMO |
$24.18
|
| Rate for Payer: Wellmark IA PPO |
$26.60
|
|
|
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
|
Facility
OP
|
$3,510.94
|
|
|
Service Code
|
CPT 11044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,191.76 |
| Max. Negotiated Rate |
$3,510.94 |
| Rate for Payer: Wellmark IA HMO |
$3,191.76
|
| Rate for Payer: Wellmark IA PPO |
$3,510.94
|
|
|
DEBRIDEMENT IN ER CHARGE
|
Professional
|
$204.00
|
|
| Hospital Charge Code |
8069137
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$142.80 |
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Medical Associates Commercial |
$75.00
|
| Rate for Payer: Midlands Choice Commercial |
$142.80
|
|
|
DEBRIDE NAIL 1-5
|
Professional
|
$106.00
|
|
|
Service Code
|
CPT 11720
|
| Hospital Charge Code |
7982850
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$74.20 |
| Rate for Payer: Aetna of IA Medicare |
$13.02
|
| Rate for Payer: Amerigroup Medicaid |
$13.46
|
| Rate for Payer: Cash Price |
$84.80
|
| Rate for Payer: Cash Price |
$84.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.62
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.28
|
| Rate for Payer: Medical Associates Commercial |
$24.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.02
|
| Rate for Payer: Midlands Choice Commercial |
$74.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.53
|
| Rate for Payer: Wellmark IA HMO |
$27.00
|
| Rate for Payer: Wellmark IA PPO |
$32.00
|
|
|
DEB SUBQ TISSUE 20 SQ CM/<
|
Professional
|
$385.00
|
|
|
Service Code
|
CPT 11042
|
| Hospital Charge Code |
7982853
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$55.05 |
| Max. Negotiated Rate |
$269.50 |
| Rate for Payer: Aetna of IA Medicare |
$55.05
|
| Rate for Payer: Amerigroup Medicaid |
$56.92
|
| Rate for Payer: Cash Price |
$308.00
|
| Rate for Payer: Cash Price |
$308.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$66.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.15
|
| Rate for Payer: Medical Associates Commercial |
$104.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.05
|
| Rate for Payer: Midlands Choice Commercial |
$269.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$82.58
|
| Rate for Payer: Wellmark IA HMO |
$113.00
|
| Rate for Payer: Wellmark IA PPO |
$132.00
|
|
|
DECELLULARIZED DERMIS 50X90
|
Facility
OP
|
$226.00
|
|
|
Service Code
|
CPT Q4125
|
| Hospital Charge Code |
8785363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$112.95 |
| Max. Negotiated Rate |
$2,069.19 |
| Rate for Payer: Aetna of IA Commercial |
$203.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$203.40
|
| Rate for Payer: Aetna of IA Medicare |
$128.82
|
| Rate for Payer: Amerigroup Medicaid |
$114.06
|
| Rate for Payer: Amerigroup Medicare |
$114.13
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$169.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$113.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$112.95
|
| Rate for Payer: Medical Associates Commercial |
$169.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$113.00
|
| Rate for Payer: Midlands Choice Commercial |
$158.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$114.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$169.50
|
| Rate for Payer: United Healthcare Commercial |
$203.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$133.34
|
| Rate for Payer: Wellmark IA HMO |
$1,881.08
|
| Rate for Payer: Wellmark IA PPO |
$2,069.19
|
|
|
DECELLULARIZED DERMIS 50X90
|
Facility
IP
|
$226.00
|
|
|
Service Code
|
CPT Q4125
|
| Hospital Charge Code |
8785363
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$158.20 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of IA Commercial |
$203.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$203.40
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$169.50
|
| Rate for Payer: Medical Associates Commercial |
$169.50
|
| Rate for Payer: Midlands Choice Commercial |
$158.20
|
| Rate for Payer: United Healthcare Commercial |
$203.40
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
IP
|
$167.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
8398095
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$116.90 |
| Max. Negotiated Rate |
$150.30 |
| Rate for Payer: Aetna of IA Commercial |
$150.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$150.30
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$125.25
|
| Rate for Payer: Medical Associates Commercial |
$125.25
|
| Rate for Payer: Midlands Choice Commercial |
$116.90
|
| Rate for Payer: United Healthcare Commercial |
$150.30
|
|
|
DECLOT VASCULAR DEVICE
|
Facility
OP
|
$167.00
|
|
|
Service Code
|
CPT 36593
|
| Hospital Charge Code |
8398095
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$83.47 |
| Max. Negotiated Rate |
$610.39 |
| Rate for Payer: Aetna of IA Commercial |
$150.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$150.30
|
| Rate for Payer: Aetna of IA Medicare |
$95.19
|
| Rate for Payer: Amerigroup Medicaid |
$84.28
|
| Rate for Payer: Amerigroup Medicare |
$84.34
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$125.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$83.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$83.47
|
| Rate for Payer: Medical Associates Commercial |
$125.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$83.50
|
| Rate for Payer: Midlands Choice Commercial |
$116.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$84.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$125.25
|
| Rate for Payer: United Healthcare Commercial |
$150.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$98.53
|
| Rate for Payer: Wellmark IA HMO |
$554.90
|
| Rate for Payer: Wellmark IA PPO |
$610.39
|
|
