|
DRUG SCREEN-TRIAGE
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
4022799
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
|
|
DRVVT LUPUS ANTICOAGULANT
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
CPT 85613
|
| Hospital Charge Code |
8093931
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
|
|
DRVVT LUPUS ANTICOAGULANT
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
CPT 85613
|
| Hospital Charge Code |
8093931
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Aetna of IA Medicare |
$37.05
|
| Rate for Payer: Amerigroup Medicaid |
$32.81
|
| Rate for Payer: Amerigroup Medicare |
$32.82
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.49
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.50
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.99
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$32.97
|
| Rate for Payer: Oscar Health of IA Commercial |
$48.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$48.75
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.35
|
| Rate for Payer: Wellmark IA HMO |
$24.18
|
| Rate for Payer: Wellmark IA PPO |
$26.60
|
|
|
DULoxetine 20 mg Cap [VDMC]
|
Facility
|
OP
|
$6.60
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10385145
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$5.94 |
| Rate for Payer: Aetna of IA Commercial |
$5.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.94
|
| Rate for Payer: Aetna of IA Medicare |
$3.76
|
| Rate for Payer: Amerigroup Medicaid |
$3.33
|
| Rate for Payer: Amerigroup Medicare |
$3.33
|
| Rate for Payer: Cash Price |
$5.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.30
|
| Rate for Payer: Medical Associates Commercial |
$4.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.30
|
| Rate for Payer: Midlands Choice Commercial |
$4.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.35
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$3.35
|
| Rate for Payer: Oscar Health of IA Commercial |
$4.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.95
|
| Rate for Payer: United Healthcare Commercial |
$5.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.89
|
|
|
DULoxetine 20 mg Cap [VDMC]
|
Facility
|
IP
|
$6.60
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10385145
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$5.94 |
| Rate for Payer: Aetna of IA Commercial |
$5.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.94
|
| Rate for Payer: Cash Price |
$5.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.95
|
| Rate for Payer: Medical Associates Commercial |
$4.95
|
| Rate for Payer: Midlands Choice Commercial |
$4.62
|
| Rate for Payer: United Healthcare Commercial |
$5.94
|
|
|
DULoxetine DR 30 mg Cap [VDMC]
|
Facility
|
OP
|
$1.69
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10385214
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of IA Commercial |
$1.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.52
|
| Rate for Payer: Aetna of IA Medicare |
$0.96
|
| Rate for Payer: Amerigroup Medicaid |
$0.85
|
| Rate for Payer: Amerigroup Medicare |
$0.85
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.27
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.84
|
| Rate for Payer: Medical Associates Commercial |
$1.27
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$1.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.86
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.86
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.27
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.00
|
|
|
DULoxetine DR 30 mg Cap [VDMC]
|
Facility
|
IP
|
$1.69
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10385214
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of IA Commercial |
$1.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.52
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.27
|
| Rate for Payer: Medical Associates Commercial |
$1.27
|
| Rate for Payer: Midlands Choice Commercial |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
|
|
DULoxetine DR 60 mg Cap [VDMC]
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10385285
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna of IA Commercial |
$4.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.00
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.33
|
| Rate for Payer: Medical Associates Commercial |
$3.33
|
| Rate for Payer: Midlands Choice Commercial |
$3.11
|
| Rate for Payer: United Healthcare Commercial |
$4.00
|
|
|
DULoxetine DR 60 mg Cap [VDMC]
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10385285
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna of IA Commercial |
$4.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.00
|
| Rate for Payer: Aetna of IA Medicare |
$2.53
|
| Rate for Payer: Amerigroup Medicaid |
$2.24
|
| Rate for Payer: Amerigroup Medicare |
$2.24
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.22
|
| Rate for Payer: Medical Associates Commercial |
$3.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.22
|
| Rate for Payer: Midlands Choice Commercial |
$3.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$2.25
|
| Rate for Payer: Oscar Health of IA Commercial |
$3.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.33
|
| Rate for Payer: United Healthcare Commercial |
$4.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.62
|
|
|
dupilumab 300 mg/2 mL SDV syringe [VDMC]
|
Facility
|
IP
|
$2,887.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
14909557
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,020.90 |
| Max. Negotiated Rate |
$2,598.30 |
| Rate for Payer: Aetna of IA Commercial |
$2,598.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,598.30
|
| Rate for Payer: Cash Price |
$2,309.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,165.25
|
| Rate for Payer: Medical Associates Commercial |
$2,165.25
|
| Rate for Payer: Midlands Choice Commercial |
$2,020.90
|
| Rate for Payer: United Healthcare Commercial |
$2,598.30
|
|
|
dupilumab 300 mg/2 mL SDV syringe [VDMC]
|
Facility
|
OP
|
$2,887.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
14909557
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,442.92 |
| Max. Negotiated Rate |
$2,598.30 |
| Rate for Payer: Aetna of IA Commercial |
$2,598.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,598.30
|
| Rate for Payer: Aetna of IA Medicare |
$1,645.59
|
| Rate for Payer: Amerigroup Medicaid |
$1,457.07
|
| Rate for Payer: Amerigroup Medicare |
$1,457.94
|
| Rate for Payer: Cash Price |
$2,309.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,165.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,443.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,442.92
|
| Rate for Payer: Medical Associates Commercial |
$2,165.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,443.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,020.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,465.15
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1,464.29
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,165.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,165.25
|
| Rate for Payer: United Healthcare Commercial |
$2,598.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,703.33
|
|
|
durvalumab 50 mg/mL 10ml SDV [VDMC]
|
Facility
|
IP
|
$14,929.92
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
20601394
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10,450.94 |
| Max. Negotiated Rate |
$13,436.93 |
| Rate for Payer: Aetna of IA Commercial |
$13,436.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13,436.93
|
| Rate for Payer: Cash Price |
$11,943.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11,197.44
|
| Rate for Payer: Medical Associates Commercial |
$11,197.44
|
| Rate for Payer: Midlands Choice Commercial |
$10,450.94
|
| Rate for Payer: United Healthcare Commercial |
$13,436.93
|
|
|
durvalumab 50 mg/mL 10ml SDV [VDMC]
|
Facility
|
OP
|
$14,929.92
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
20601394
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7,461.97 |
| Max. Negotiated Rate |
$13,436.93 |
| Rate for Payer: Aetna of IA Commercial |
$13,436.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13,436.93
|
| Rate for Payer: Aetna of IA Medicare |
$8,510.05
|
| Rate for Payer: Amerigroup Medicaid |
$7,535.13
|
| Rate for Payer: Amerigroup Medicare |
$7,539.61
|
| Rate for Payer: Cash Price |
$11,943.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11,197.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7,464.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7,461.97
|
| Rate for Payer: Medical Associates Commercial |
$11,197.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$7,464.96
|
| Rate for Payer: Midlands Choice Commercial |
$10,450.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,576.93
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$7,572.46
|
| Rate for Payer: Oscar Health of IA Commercial |
$11,197.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$11,197.44
|
| Rate for Payer: United Healthcare Commercial |
$13,436.93
|
| Rate for Payer: United Healthcare Managed Medicare |
$8,808.65
|
|
|
durvalumab 50 mg/mL 2.4ml SDV [VDMC]
|
Facility
|
IP
|
$3,621.20
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
20601145
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,534.84 |
| Max. Negotiated Rate |
$3,259.08 |
| Rate for Payer: Aetna of IA Commercial |
$3,259.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,259.08
|
| Rate for Payer: Cash Price |
$2,896.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,715.90
|
| Rate for Payer: Medical Associates Commercial |
$2,715.90
|
| Rate for Payer: Midlands Choice Commercial |
$2,534.84
|
| Rate for Payer: United Healthcare Commercial |
$3,259.08
|
|
|
durvalumab 50 mg/mL 2.4ml SDV [VDMC]
|
Facility
|
OP
|
$3,621.20
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
20601145
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,809.88 |
| Max. Negotiated Rate |
$3,259.08 |
| Rate for Payer: Aetna of IA Commercial |
$3,259.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,259.08
|
| Rate for Payer: Aetna of IA Medicare |
$2,064.08
|
| Rate for Payer: Amerigroup Medicaid |
$1,827.62
|
| Rate for Payer: Amerigroup Medicare |
$1,828.71
|
| Rate for Payer: Cash Price |
$2,896.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,715.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,810.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,809.88
|
| Rate for Payer: Medical Associates Commercial |
$2,715.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,810.60
|
| Rate for Payer: Midlands Choice Commercial |
$2,534.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,837.76
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1,836.67
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,715.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,715.90
|
| Rate for Payer: United Healthcare Commercial |
$3,259.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,136.51
|
|
|
dutasteride 0.5 mg Cap [VDMC]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10385354
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of IA Commercial |
$1.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.48
|
| Rate for Payer: Aetna of IA Medicare |
$0.93
|
| Rate for Payer: Amerigroup Medicaid |
$0.83
|
| Rate for Payer: Amerigroup Medicare |
$0.83
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.23
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.82
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.82
|
| Rate for Payer: Medical Associates Commercial |
$1.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.82
|
| Rate for Payer: Midlands Choice Commercial |
$1.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.83
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.83
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.23
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.97
|
|
|
dutasteride 0.5 mg Cap [VDMC]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10385354
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of IA Commercial |
$1.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.48
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.23
|
| Rate for Payer: Medical Associates Commercial |
$1.23
|
| Rate for Payer: Midlands Choice Commercial |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
|
|
DU TUBE
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
CPT 86905
|
| Hospital Charge Code |
7912828
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$107.07 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Aetna of IA Medicare |
$29.64
|
| Rate for Payer: Amerigroup Medicaid |
$26.24
|
| Rate for Payer: Amerigroup Medicare |
$26.26
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$25.99
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.00
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.39
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$26.37
|
| Rate for Payer: Oscar Health of IA Commercial |
$39.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.00
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.68
|
| Rate for Payer: Wellmark IA HMO |
$97.34
|
| Rate for Payer: Wellmark IA PPO |
$107.07
|
|
|
DU TUBE
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
CPT 86905
|
| Hospital Charge Code |
7912828
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
|
|
DX FIBERTAK SUTURE ANCHOR, ST NDLS
|
Facility
|
OP
|
$837.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783236
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.33 |
| Max. Negotiated Rate |
$753.30 |
| Rate for Payer: Aetna of IA Commercial |
$753.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$753.30
|
| Rate for Payer: Aetna of IA Medicare |
$477.09
|
| Rate for Payer: Amerigroup Medicaid |
$422.43
|
| Rate for Payer: Amerigroup Medicare |
$422.68
|
| Rate for Payer: Cash Price |
$669.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$627.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$418.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$418.33
|
| Rate for Payer: Medical Associates Commercial |
$627.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$418.50
|
| Rate for Payer: Midlands Choice Commercial |
$585.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$424.78
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$424.53
|
| Rate for Payer: Oscar Health of IA Commercial |
$627.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$627.75
|
| Rate for Payer: United Healthcare Commercial |
$753.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$493.83
|
|
|
DX FIBERTAK SUTURE ANCHOR, ST NDLS
|
Facility
|
IP
|
$837.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783236
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$585.90 |
| Max. Negotiated Rate |
$753.30 |
| Rate for Payer: Aetna of IA Commercial |
$753.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$753.30
|
| Rate for Payer: Cash Price |
$669.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$627.75
|
| Rate for Payer: Medical Associates Commercial |
$627.75
|
| Rate for Payer: Midlands Choice Commercial |
$585.90
|
| Rate for Payer: United Healthcare Commercial |
$753.30
|
|
|
Dysequilibrium
|
Facility
|
IP
|
$6,097.37
|
|
|
Service Code
|
MS-DRG 149
|
| Hospital Charge Code |
29
|
| Min. Negotiated Rate |
$6,009.00 |
| Max. Negotiated Rate |
$6,097.37 |
| Rate for Payer: Amerigroup Medicaid |
$6,067.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,009.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,097.37
|
|
|
E0332 RBC CPD AS1 500 LR Irr
|
Facility
|
OP
|
$532.00
|
|
|
Service Code
|
CPT P9040
|
| Hospital Charge Code |
6702794
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$265.89 |
| Max. Negotiated Rate |
$1,444.48 |
| Rate for Payer: Aetna of IA Medicare |
$303.24
|
| Rate for Payer: Aetna of IA Commercial |
$478.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$478.80
|
| Rate for Payer: Amerigroup Medicaid |
$268.50
|
| Rate for Payer: Amerigroup Medicare |
$268.66
|
| Rate for Payer: Cash Price |
$425.60
|
| Rate for Payer: Cash Price |
$425.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$399.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$266.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$265.89
|
| Rate for Payer: Medical Associates Commercial |
$399.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$266.00
|
| Rate for Payer: Midlands Choice Commercial |
$372.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$269.99
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$269.83
|
| Rate for Payer: Oscar Health of IA Commercial |
$399.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$399.00
|
| Rate for Payer: United Healthcare Commercial |
$478.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$313.88
|
| Rate for Payer: Wellmark IA HMO |
$1,313.16
|
| Rate for Payer: Wellmark IA PPO |
$1,444.48
|
|
|
E0332 RBC CPD AS1 500 LR Irr
|
Facility
|
IP
|
$532.00
|
|
|
Service Code
|
CPT P9040
|
| Hospital Charge Code |
6702794
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$372.40 |
| Max. Negotiated Rate |
$478.80 |
| Rate for Payer: Aetna of IA Commercial |
$478.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$478.80
|
| Rate for Payer: Cash Price |
$425.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$399.00
|
| Rate for Payer: Medical Associates Commercial |
$399.00
|
| Rate for Payer: Midlands Choice Commercial |
$372.40
|
| Rate for Payer: United Healthcare Commercial |
$478.80
|
|
|
E0336 RBC CPD AS1 500 LR
|
Facility
|
OP
|
$532.00
|
|
|
Service Code
|
CPT P9016
|
| Hospital Charge Code |
6702786
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$265.89 |
| Max. Negotiated Rate |
$1,444.48 |
| Rate for Payer: Aetna of IA Commercial |
$478.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$478.80
|
| Rate for Payer: Aetna of IA Medicare |
$303.24
|
| Rate for Payer: Amerigroup Medicaid |
$268.50
|
| Rate for Payer: Amerigroup Medicare |
$268.66
|
| Rate for Payer: Cash Price |
$425.60
|
| Rate for Payer: Cash Price |
$425.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$399.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$266.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$265.89
|
| Rate for Payer: Medical Associates Commercial |
$399.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$266.00
|
| Rate for Payer: Midlands Choice Commercial |
$372.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$269.99
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$269.83
|
| Rate for Payer: Oscar Health of IA Commercial |
$399.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$399.00
|
| Rate for Payer: United Healthcare Commercial |
$478.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$313.88
|
| Rate for Payer: Wellmark IA HMO |
$1,313.16
|
| Rate for Payer: Wellmark IA PPO |
$1,444.48
|
|
