|
ETHICON ENDO GIA GUN
|
Facility
|
IP
|
$480.00
|
|
| Hospital Charge Code |
8026300
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna of IA Commercial |
$432.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$432.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$360.00
|
| Rate for Payer: Medical Associates Commercial |
$360.00
|
| Rate for Payer: Midlands Choice Commercial |
$336.00
|
| Rate for Payer: United Healthcare Commercial |
$432.00
|
|
|
etomidate 2 mg/mL IV 10 ml SDV [VDMC]
|
Facility
|
OP
|
$28.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10387670
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.61 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Aetna of IA Commercial |
$25.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.22
|
| Rate for Payer: Aetna of IA Medicare |
$15.97
|
| Rate for Payer: Amerigroup Medicaid |
$16.16
|
| Rate for Payer: Amerigroup Medicare |
$12.74
|
| Rate for Payer: Cash Price |
$22.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.01
|
| Rate for Payer: Medical Associates Commercial |
$21.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.61
|
| Rate for Payer: Midlands Choice Commercial |
$19.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.50
|
| Rate for Payer: United Healthcare Commercial |
$25.22
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.53
|
|
|
etomidate 2 mg/mL IV 10 ml SDV [VDMC]
|
Facility
|
IP
|
$28.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10387670
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.62 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Aetna of IA Commercial |
$25.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.22
|
| Rate for Payer: Cash Price |
$22.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.02
|
| Rate for Payer: Medical Associates Commercial |
$21.02
|
| Rate for Payer: Midlands Choice Commercial |
$19.62
|
| Rate for Payer: United Healthcare Commercial |
$25.22
|
|
|
etonogestrel 68 mg Imp[VDMC]
|
Facility
|
OP
|
$2,412.56
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
12485011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,085.65 |
| Max. Negotiated Rate |
$2,171.30 |
| Rate for Payer: Aetna of IA Commercial |
$2,171.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,171.30
|
| Rate for Payer: Aetna of IA Medicare |
$1,375.16
|
| Rate for Payer: Amerigroup Medicaid |
$1,391.56
|
| Rate for Payer: Amerigroup Medicare |
$1,096.51
|
| Rate for Payer: Cash Price |
$1,930.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,809.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,085.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,378.05
|
| Rate for Payer: Medical Associates Commercial |
$1,809.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,085.65
|
| Rate for Payer: Midlands Choice Commercial |
$1,688.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,398.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,248.50
|
| Rate for Payer: United Healthcare Commercial |
$2,171.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,423.41
|
|
|
etonogestrel 68 mg Imp[VDMC]
|
Facility
|
IP
|
$2,412.56
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
12485011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,688.79 |
| Max. Negotiated Rate |
$2,171.30 |
| Rate for Payer: Aetna of IA Commercial |
$2,171.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,171.30
|
| Rate for Payer: Cash Price |
$1,930.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,809.42
|
| Rate for Payer: Medical Associates Commercial |
$1,809.42
|
| Rate for Payer: Midlands Choice Commercial |
$1,688.79
|
| Rate for Payer: United Healthcare Commercial |
$2,171.30
|
|
|
EVALUATION 60 MIN
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
CPT 90791 AJ|HO
|
| Hospital Charge Code |
4919448
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$105.10 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Amerigroup Medicaid |
$106.13
|
| Rate for Payer: Cash Price |
$164.00
|
| Rate for Payer: Cash Price |
$164.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$105.10
|
| Rate for Payer: Medical Associates Commercial |
$153.75
|
| Rate for Payer: Midlands Choice Commercial |
$143.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$105.62
|
| Rate for Payer: Optum Behavioral Health |
$166.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$153.75
|
| Rate for Payer: United Healthcare Commercial |
$224.11
|
| Rate for Payer: Wellmark IA HMO WHPI |
$232.50
|
| Rate for Payer: Wellmark IA PPO |
$232.50
|
|
|
EVALUATION 60 MIN
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
CPT 90791 AJ|HO
|
| Hospital Charge Code |
8052933
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$105.10 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Amerigroup Medicaid |
$106.13
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$105.10
|
| Rate for Payer: Medical Associates Commercial |
$180.00
|
| Rate for Payer: Midlands Choice Commercial |
$168.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$105.62
|
| Rate for Payer: Optum Behavioral Health |
$166.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$180.00
|
| Rate for Payer: United Healthcare Commercial |
$224.11
|
| Rate for Payer: Wellmark IA HMO WHPI |
$232.50
|
| Rate for Payer: Wellmark IA PPO |
$232.50
|
|
|
EVALUATION OF SPEECH SOUND PRODUCTION
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 92523 GN
|
| Hospital Charge Code |
8925747
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$103.50 |
| Max. Negotiated Rate |
$228.83 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Aetna of IA Medicare |
$131.10
|
| Rate for Payer: Amerigroup Medicaid |
$132.66
|
| Rate for Payer: Amerigroup Medicare |
$104.54
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$103.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$131.38
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$103.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$133.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$119.02
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$135.70
|
| Rate for Payer: Wellmark IA HMO WHPI |
$207.74
|
| Rate for Payer: Wellmark IA PPO |
$228.83
|
|
|
EVALUATION OF SPEECH SOUND PRODUCTION
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 92523 GN
|
| Hospital Charge Code |
8925747
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
|
|
Everolimus Level DMCL
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
8820559
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna of IA Commercial |
$216.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$216.00
|
| Rate for Payer: Aetna of IA Medicare |
$136.80
|
| Rate for Payer: Amerigroup Medicaid |
$138.43
|
| Rate for Payer: Amerigroup Medicare |
$109.08
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$180.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$108.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$137.09
|
| Rate for Payer: Medical Associates Commercial |
$180.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$108.00
|
| Rate for Payer: Midlands Choice Commercial |
$168.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$139.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$124.20
|
| Rate for Payer: United Healthcare Commercial |
$216.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$141.60
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
Everolimus Level DMCL
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
8820559
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$168.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna of IA Commercial |
$216.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$216.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$180.00
|
| Rate for Payer: Medical Associates Commercial |
$180.00
|
| Rate for Payer: Midlands Choice Commercial |
$168.00
|
| Rate for Payer: United Healthcare Commercial |
$216.00
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
4862822
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$366.75 |
| Max. Negotiated Rate |
$903.62 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Aetna of IA Medicare |
$464.55
|
| Rate for Payer: Amerigroup Medicaid |
$470.09
|
| Rate for Payer: Amerigroup Medicare |
$370.42
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$366.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$465.53
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$366.75
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$472.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$421.76
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$480.85
|
| Rate for Payer: Wellmark IA HMO WHPI |
$820.31
|
| Rate for Payer: Wellmark IA PPO |
$903.62
|
|
|
EXC FACE-MM B9+MARG 0.5 CM/<
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
CPT 11440
|
| Hospital Charge Code |
4862822
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
|
|
EXC FACE-MM B9+MARG 0.6-1 CM
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
CPT 11441
|
| Hospital Charge Code |
7982974
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
|
|
EXC FACE-MM B9+MARG 0.6-1 CM
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
CPT 11441
|
| Hospital Charge Code |
7982974
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$366.75 |
| Max. Negotiated Rate |
$903.62 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Aetna of IA Medicare |
$464.55
|
| Rate for Payer: Amerigroup Medicaid |
$470.09
|
| Rate for Payer: Amerigroup Medicare |
$370.42
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$366.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$465.53
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$366.75
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$472.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$421.76
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$480.85
|
| Rate for Payer: Wellmark IA HMO WHPI |
$820.31
|
| Rate for Payer: Wellmark IA PPO |
$903.62
|
|
|
EXC FACE-MM B9+MARG 1.1-2 CM
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
CPT 11442
|
| Hospital Charge Code |
7982973
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$366.75 |
| Max. Negotiated Rate |
$903.62 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Aetna of IA Medicare |
$464.55
|
| Rate for Payer: Amerigroup Medicaid |
$470.09
|
| Rate for Payer: Amerigroup Medicare |
$370.42
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$366.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$465.53
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$366.75
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$472.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$421.76
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$480.85
|
| Rate for Payer: Wellmark IA HMO WHPI |
$820.31
|
| Rate for Payer: Wellmark IA PPO |
$903.62
|
|
|
EXC FACE-MM B9+MARG 1.1-2 CM
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
CPT 11442
|
| Hospital Charge Code |
7982973
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
|
|
EXC FACE-MM B9+MARG 2.1-3 CM
|
Facility
|
IP
|
$3,393.00
|
|
|
Service Code
|
CPT 11443
|
| Hospital Charge Code |
7982972
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,375.10 |
| Max. Negotiated Rate |
$3,053.70 |
| Rate for Payer: Aetna of IA Commercial |
$3,053.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,053.70
|
| Rate for Payer: Cash Price |
$2,714.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,544.75
|
| Rate for Payer: Medical Associates Commercial |
$2,544.75
|
| Rate for Payer: Midlands Choice Commercial |
$2,375.10
|
| Rate for Payer: United Healthcare Commercial |
$3,053.70
|
|
|
EXC FACE-MM B9+MARG 2.1-3 CM
|
Facility
|
OP
|
$3,393.00
|
|
|
Service Code
|
CPT 11443
|
| Hospital Charge Code |
7982972
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,526.85 |
| Max. Negotiated Rate |
$3,053.70 |
| Rate for Payer: Aetna of IA Commercial |
$3,053.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,053.70
|
| Rate for Payer: Aetna of IA Medicare |
$1,934.01
|
| Rate for Payer: Amerigroup Medicaid |
$1,957.08
|
| Rate for Payer: Amerigroup Medicare |
$1,542.12
|
| Rate for Payer: Cash Price |
$2,714.40
|
| Rate for Payer: Cash Price |
$2,714.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,544.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,526.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,938.08
|
| Rate for Payer: Medical Associates Commercial |
$2,544.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,526.85
|
| Rate for Payer: Midlands Choice Commercial |
$2,375.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,966.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,755.88
|
| Rate for Payer: United Healthcare Commercial |
$3,053.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,001.87
|
| Rate for Payer: Wellmark IA HMO WHPI |
$2,701.29
|
| Rate for Payer: Wellmark IA PPO |
$2,975.61
|
|
|
EXC FACE-MM B9+MARG 3.1-4 CM
|
Facility
|
OP
|
$3,393.00
|
|
|
Service Code
|
CPT 11444
|
| Hospital Charge Code |
7982971
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,526.85 |
| Max. Negotiated Rate |
$3,053.70 |
| Rate for Payer: Aetna of IA Commercial |
$3,053.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,053.70
|
| Rate for Payer: Aetna of IA Medicare |
$1,934.01
|
| Rate for Payer: Amerigroup Medicaid |
$1,957.08
|
| Rate for Payer: Amerigroup Medicare |
$1,542.12
|
| Rate for Payer: Cash Price |
$2,714.40
|
| Rate for Payer: Cash Price |
$2,714.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,544.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,526.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,938.08
|
| Rate for Payer: Medical Associates Commercial |
$2,544.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,526.85
|
| Rate for Payer: Midlands Choice Commercial |
$2,375.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,966.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,755.88
|
| Rate for Payer: United Healthcare Commercial |
$3,053.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,001.87
|
| Rate for Payer: Wellmark IA HMO WHPI |
$2,701.29
|
| Rate for Payer: Wellmark IA PPO |
$2,975.61
|
|
|
EXC FACE-MM B9+MARG 3.1-4 CM
|
Facility
|
IP
|
$3,393.00
|
|
|
Service Code
|
CPT 11444
|
| Hospital Charge Code |
7982971
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,375.10 |
| Max. Negotiated Rate |
$3,053.70 |
| Rate for Payer: Aetna of IA Commercial |
$3,053.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,053.70
|
| Rate for Payer: Cash Price |
$2,714.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,544.75
|
| Rate for Payer: Medical Associates Commercial |
$2,544.75
|
| Rate for Payer: Midlands Choice Commercial |
$2,375.10
|
| Rate for Payer: United Healthcare Commercial |
$3,053.70
|
|
|
EXC F/E/E/N/L MAL+MRG 0.5CM<
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
CPT 11640
|
| Hospital Charge Code |
7982970
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$366.75 |
| Max. Negotiated Rate |
$903.62 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Aetna of IA Medicare |
$464.55
|
| Rate for Payer: Amerigroup Medicaid |
$470.09
|
| Rate for Payer: Amerigroup Medicare |
$370.42
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$366.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$465.53
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$366.75
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$472.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$421.76
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$480.85
|
| Rate for Payer: Wellmark IA HMO WHPI |
$820.31
|
| Rate for Payer: Wellmark IA PPO |
$903.62
|
|
|
EXC F/E/E/N/L MAL+MRG 0.5CM<
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
CPT 11640
|
| Hospital Charge Code |
7982970
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
|
|
EXC F/E/E/N/L MAL+MRG 0.6-1
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
CPT 11641
|
| Hospital Charge Code |
7982969
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$366.75 |
| Max. Negotiated Rate |
$903.62 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Aetna of IA Medicare |
$464.55
|
| Rate for Payer: Amerigroup Medicaid |
$470.09
|
| Rate for Payer: Amerigroup Medicare |
$370.42
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$366.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$465.53
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$366.75
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$472.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$421.76
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$480.85
|
| Rate for Payer: Wellmark IA HMO WHPI |
$820.31
|
| Rate for Payer: Wellmark IA PPO |
$903.62
|
|
|
EXC F/E/E/N/L MAL+MRG 0.6-1
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
CPT 11641
|
| Hospital Charge Code |
7982969
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
|
