|
FHL IMPLANT SYSTEM, 6.25MM
|
Facility
IP
|
$2,691.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8784970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,883.70 |
| Max. Negotiated Rate |
$2,421.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,421.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,421.90
|
| Rate for Payer: Cash Price |
$2,152.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,018.25
|
| Rate for Payer: Medical Associates Commercial |
$2,018.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,883.70
|
| Rate for Payer: United Healthcare Commercial |
$2,421.90
|
|
|
FHL IMPLANT SYSTEM, 6.25MM
|
Facility
OP
|
$2,691.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8784970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,344.96 |
| Max. Negotiated Rate |
$2,421.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,421.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,421.90
|
| Rate for Payer: Aetna of IA Medicare |
$1,533.87
|
| Rate for Payer: Amerigroup Medicaid |
$1,358.15
|
| Rate for Payer: Amerigroup Medicare |
$1,358.96
|
| Rate for Payer: Cash Price |
$2,152.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,018.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,345.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,344.96
|
| Rate for Payer: Medical Associates Commercial |
$2,018.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,345.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,883.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,365.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,018.25
|
| Rate for Payer: United Healthcare Commercial |
$2,421.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,587.69
|
|
|
FIBERTAPE
|
Facility
IP
|
$129.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8047071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
|
|
FIBERTAPE
|
Facility
OP
|
$129.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8047071
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$64.47 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Aetna of IA Medicare |
$73.53
|
| Rate for Payer: Amerigroup Medicaid |
$65.11
|
| Rate for Payer: Amerigroup Medicare |
$65.14
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$64.47
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.50
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$65.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$96.75
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
|
|
FIBERWIRE 2.0
|
Facility
OP
|
$56.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27.99 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna of IA Commercial |
$50.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.40
|
| Rate for Payer: Aetna of IA Medicare |
$31.92
|
| Rate for Payer: Amerigroup Medicaid |
$28.26
|
| Rate for Payer: Amerigroup Medicare |
$28.28
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27.99
|
| Rate for Payer: Medical Associates Commercial |
$42.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.00
|
| Rate for Payer: Midlands Choice Commercial |
$39.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$28.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.00
|
| Rate for Payer: United Healthcare Commercial |
$50.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.04
|
|
|
FIBERWIRE 2.0
|
Facility
IP
|
$56.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046960
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna of IA Commercial |
$50.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.40
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.00
|
| Rate for Payer: Medical Associates Commercial |
$42.00
|
| Rate for Payer: Midlands Choice Commercial |
$39.20
|
| Rate for Payer: United Healthcare Commercial |
$50.40
|
|
|
FIBERWIRE 2.0-1
|
Facility
IP
|
$35.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8047069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna of IA Commercial |
$31.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$31.50
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.25
|
| Rate for Payer: Medical Associates Commercial |
$26.25
|
| Rate for Payer: Midlands Choice Commercial |
$24.50
|
| Rate for Payer: United Healthcare Commercial |
$31.50
|
|
|
FIBERWIRE 2.0-1
|
Facility
OP
|
$35.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8047069
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.49 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna of IA Commercial |
$31.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$31.50
|
| Rate for Payer: Aetna of IA Medicare |
$19.95
|
| Rate for Payer: Amerigroup Medicaid |
$17.66
|
| Rate for Payer: Amerigroup Medicare |
$17.68
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.49
|
| Rate for Payer: Medical Associates Commercial |
$26.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.50
|
| Rate for Payer: Midlands Choice Commercial |
$24.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.25
|
| Rate for Payer: United Healthcare Commercial |
$31.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$20.65
|
|
|
FIBERWIRE 2-0 LOOP 60'' W/DIAMOND NEEDLE
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8047070
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25.99 |
| 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: 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: 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: Partners Health Alliance Commercial |
$39.00
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.68
|
|
|
FIBERWIRE 2-0 LOOP 60'' W/DIAMOND NEEDLE
|
Facility
IP
|
$52.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8047070
|
|
Hospital Revenue Code
|
278
|
| 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
|
|
|
FIBER WIRE BLUE W/TPR 1/2 CIR NEEDLE
|
Facility
IP
|
$40.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8860533
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
|
|
FIBER WIRE BLUE W/TPR 1/2 CIR NEEDLE
|
Facility
OP
|
$40.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8860533
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Aetna of IA Medicare |
$22.80
|
| Rate for Payer: Amerigroup Medicaid |
$20.19
|
| Rate for Payer: Amerigroup Medicare |
$20.20
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.99
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
|
|
Fibrinogen DMCL
|
Facility
IP
|
$81.00
|
|
|
Service Code
|
CPT 85384
|
| Hospital Charge Code |
8037846
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$72.90 |
| Rate for Payer: Aetna of IA Commercial |
$72.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$72.90
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$60.75
|
| Rate for Payer: Medical Associates Commercial |
$60.75
|
| Rate for Payer: Midlands Choice Commercial |
$56.70
|
| Rate for Payer: United Healthcare Commercial |
$72.90
|
|
|
Fibrinogen DMCL
|
Facility
OP
|
$81.00
|
|
|
Service Code
|
CPT 85384
|
| Hospital Charge Code |
8037846
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$72.90 |
| Rate for Payer: Aetna of IA Commercial |
$72.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$72.90
|
| Rate for Payer: Aetna of IA Medicare |
$46.17
|
| Rate for Payer: Amerigroup Medicaid |
$40.88
|
| Rate for Payer: Amerigroup Medicare |
$40.90
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$60.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$40.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40.48
|
| Rate for Payer: Medical Associates Commercial |
$60.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$40.50
|
| Rate for Payer: Midlands Choice Commercial |
$56.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$60.75
|
| Rate for Payer: United Healthcare Commercial |
$72.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$47.79
|
| Rate for Payer: Wellmark IA HMO |
$24.18
|
| Rate for Payer: Wellmark IA PPO |
$26.60
|
|
|
Filgrastim aafi 480 mcg/0.8 mL PFS syringe
|
Facility
IP
|
$1,372.54
|
|
|
Service Code
|
CPT Q5110
|
| Hospital Charge Code |
43799932
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$960.78 |
| Max. Negotiated Rate |
$1,235.29 |
| Rate for Payer: Aetna of IA Commercial |
$1,235.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,235.29
|
| Rate for Payer: Cash Price |
$1,098.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,029.40
|
| Rate for Payer: Medical Associates Commercial |
$1,029.40
|
| Rate for Payer: Midlands Choice Commercial |
$960.78
|
| Rate for Payer: United Healthcare Commercial |
$1,235.29
|
|
|
Filgrastim aafi 480 mcg/0.8 mL PFS syringe
|
Facility
OP
|
$1,372.54
|
|
|
Service Code
|
CPT Q5110
|
| Hospital Charge Code |
43799932
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$686.00 |
| Max. Negotiated Rate |
$1,235.29 |
| Rate for Payer: Aetna of IA Commercial |
$1,235.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,235.29
|
| Rate for Payer: Aetna of IA Medicare |
$782.35
|
| Rate for Payer: Amerigroup Medicaid |
$692.72
|
| Rate for Payer: Amerigroup Medicare |
$693.13
|
| Rate for Payer: Cash Price |
$1,098.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,029.40
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$686.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$686.00
|
| Rate for Payer: Medical Associates Commercial |
$1,029.40
|
| Rate for Payer: Medical Associates Managed Medicare |
$686.27
|
| Rate for Payer: Midlands Choice Commercial |
$960.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$696.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,029.40
|
| Rate for Payer: United Healthcare Commercial |
$1,235.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$809.80
|
|
|
Filgrastim ayow 300 mcg/0.5 mL PFS syringe
|
Facility
IP
|
$633.76
|
|
|
Service Code
|
CPT Q5125
|
| Hospital Charge Code |
43799943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$443.63 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna of IA Commercial |
$570.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$570.38
|
| Rate for Payer: Cash Price |
$507.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$475.32
|
| Rate for Payer: Medical Associates Commercial |
$475.32
|
| Rate for Payer: Midlands Choice Commercial |
$443.63
|
| Rate for Payer: United Healthcare Commercial |
$570.38
|
|
|
Filgrastim ayow 300 mcg/0.5 mL PFS syringe
|
Facility
OP
|
$633.76
|
|
|
Service Code
|
CPT Q5125
|
| Hospital Charge Code |
43799943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$316.75 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna of IA Commercial |
$570.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$570.38
|
| Rate for Payer: Aetna of IA Medicare |
$361.24
|
| Rate for Payer: Amerigroup Medicaid |
$319.86
|
| Rate for Payer: Amerigroup Medicare |
$320.05
|
| Rate for Payer: Cash Price |
$507.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$475.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$316.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$316.75
|
| Rate for Payer: Medical Associates Commercial |
$475.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$316.88
|
| Rate for Payer: Midlands Choice Commercial |
$443.63
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$321.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$475.32
|
| Rate for Payer: United Healthcare Commercial |
$570.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$373.92
|
|
|
finasteride 5 mg Tab
|
Facility
IP
|
$3.21
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of IA Commercial |
$2.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.89
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.41
|
| Rate for Payer: Medical Associates Commercial |
$2.41
|
| Rate for Payer: Midlands Choice Commercial |
$2.25
|
| Rate for Payer: United Healthcare Commercial |
$2.89
|
|
|
finasteride 5 mg Tab
|
Facility
OP
|
$3.21
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of IA Commercial |
$2.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.89
|
| Rate for Payer: Aetna of IA Medicare |
$1.83
|
| Rate for Payer: Amerigroup Medicaid |
$1.62
|
| Rate for Payer: Amerigroup Medicare |
$1.62
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.41
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.60
|
| Rate for Payer: Medical Associates Commercial |
$2.41
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.60
|
| Rate for Payer: Midlands Choice Commercial |
$2.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.41
|
| Rate for Payer: United Healthcare Commercial |
$2.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.89
|
|
|
FIXATION DEVICE DERMASORB FASTENER
|
Facility
OP
|
$298.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$148.94 |
| Max. Negotiated Rate |
$268.20 |
| Rate for Payer: Aetna of IA Commercial |
$268.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$268.20
|
| Rate for Payer: Aetna of IA Medicare |
$169.86
|
| Rate for Payer: Amerigroup Medicaid |
$150.40
|
| Rate for Payer: Amerigroup Medicare |
$150.49
|
| Rate for Payer: Cash Price |
$238.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$223.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$149.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$148.94
|
| Rate for Payer: Medical Associates Commercial |
$223.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$149.00
|
| Rate for Payer: Midlands Choice Commercial |
$208.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$151.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$223.50
|
| Rate for Payer: United Healthcare Commercial |
$268.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$175.82
|
|
|
FIXATION DEVICE DERMASORB FASTENER
|
Facility
IP
|
$298.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046250
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$208.60 |
| Max. Negotiated Rate |
$268.20 |
| Rate for Payer: Aetna of IA Commercial |
$268.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$268.20
|
| Rate for Payer: Cash Price |
$238.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$223.50
|
| Rate for Payer: Medical Associates Commercial |
$223.50
|
| Rate for Payer: Midlands Choice Commercial |
$208.60
|
| Rate for Payer: United Healthcare Commercial |
$268.20
|
|
|
flecainide 100 mg Tab
|
Facility
IP
|
$1.50
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of IA Commercial |
$1.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.35
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
|
|
flecainide 100 mg Tab
|
Facility
OP
|
$1.50
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of IA Commercial |
$1.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.35
|
| Rate for Payer: Aetna of IA Medicare |
$0.86
|
| Rate for Payer: Amerigroup Medicaid |
$0.76
|
| Rate for Payer: Amerigroup Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.75
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.75
|
| Rate for Payer: Midlands Choice Commercial |
$1.05
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.89
|
|
|
fluconazole 100 mg Tab
|
Facility
OP
|
$6.04
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$5.44 |
| Rate for Payer: Aetna of IA Commercial |
$5.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.44
|
| Rate for Payer: Aetna of IA Medicare |
$3.44
|
| Rate for Payer: Amerigroup Medicaid |
$3.05
|
| Rate for Payer: Amerigroup Medicare |
$3.05
|
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.53
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.02
|
| Rate for Payer: Medical Associates Commercial |
$4.53
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.02
|
| Rate for Payer: Midlands Choice Commercial |
$4.23
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.53
|
| Rate for Payer: United Healthcare Commercial |
$5.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.56
|
|
