|
GENERAL HEALTH PANEL
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
7805074
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.97 |
| Max. Negotiated Rate |
$309.60 |
| Rate for Payer: Aetna of IA Commercial |
$309.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$309.60
|
| Rate for Payer: Aetna of IA Medicare |
$196.08
|
| Rate for Payer: Amerigroup Medicaid |
$198.42
|
| Rate for Payer: Amerigroup Medicare |
$156.35
|
| Rate for Payer: Cash Price |
$275.20
|
| Rate for Payer: Cash Price |
$275.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$258.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$154.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$196.49
|
| Rate for Payer: Medical Associates Commercial |
$258.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$154.80
|
| Rate for Payer: Midlands Choice Commercial |
$240.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$199.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$178.02
|
| Rate for Payer: United Healthcare Commercial |
$309.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$202.96
|
| Rate for Payer: Wellmark IA HMO WHPI |
$60.97
|
| Rate for Payer: Wellmark IA PPO |
$67.17
|
|
|
GENERAL HEALTH PANEL
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
7805074
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$240.80 |
| Max. Negotiated Rate |
$309.60 |
| Rate for Payer: Aetna of IA Commercial |
$309.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$309.60
|
| Rate for Payer: Cash Price |
$275.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$258.00
|
| Rate for Payer: Medical Associates Commercial |
$258.00
|
| Rate for Payer: Midlands Choice Commercial |
$240.80
|
| Rate for Payer: United Healthcare Commercial |
$309.60
|
|
|
GENERAL PHYSICAL
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8015871
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of IA Commercial |
$63.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.50
|
| Rate for Payer: Medical Associates Commercial |
$52.50
|
| Rate for Payer: Midlands Choice Commercial |
$49.00
|
| Rate for Payer: United Healthcare Commercial |
$63.00
|
|
|
GENERAL PHYSICAL
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8015871
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of IA Commercial |
$63.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.00
|
| Rate for Payer: Aetna of IA Medicare |
$39.90
|
| Rate for Payer: Amerigroup Medicaid |
$40.38
|
| Rate for Payer: Amerigroup Medicare |
$31.82
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$39.98
|
| Rate for Payer: Medical Associates Commercial |
$52.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.50
|
| Rate for Payer: Midlands Choice Commercial |
$49.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$40.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.22
|
| Rate for Payer: United Healthcare Commercial |
$63.00
|
|
|
gentamicin 0.1% cream 15gm Tube [VDMC]
|
Facility
|
OP
|
$33.68
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$30.31 |
| Rate for Payer: Aetna of IA Commercial |
$30.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.31
|
| Rate for Payer: Aetna of IA Medicare |
$19.20
|
| Rate for Payer: Amerigroup Medicaid |
$19.43
|
| Rate for Payer: Amerigroup Medicare |
$15.31
|
| Rate for Payer: Cash Price |
$26.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.26
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.24
|
| Rate for Payer: Medical Associates Commercial |
$25.26
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.16
|
| Rate for Payer: Midlands Choice Commercial |
$23.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.43
|
| Rate for Payer: United Healthcare Commercial |
$30.31
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.87
|
|
|
gentamicin 0.1% cream 15gm Tube [VDMC]
|
Facility
|
IP
|
$33.68
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.58 |
| Max. Negotiated Rate |
$30.31 |
| Rate for Payer: Aetna of IA Commercial |
$30.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.31
|
| Rate for Payer: Cash Price |
$26.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.26
|
| Rate for Payer: Medical Associates Commercial |
$25.26
|
| Rate for Payer: Midlands Choice Commercial |
$23.58
|
| Rate for Payer: United Healthcare Commercial |
$30.31
|
|
|
gentamicin 10 mg/mL 2ml [VDMC]
|
Facility
|
IP
|
$27.58
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391689
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.31 |
| Max. Negotiated Rate |
$24.82 |
| Rate for Payer: Aetna of IA Commercial |
$24.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.82
|
| Rate for Payer: Cash Price |
$22.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.68
|
| Rate for Payer: Medical Associates Commercial |
$20.68
|
| Rate for Payer: Midlands Choice Commercial |
$19.31
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
|
|
gentamicin 10 mg/mL 2ml [VDMC]
|
Facility
|
OP
|
$27.58
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391689
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.41 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$24.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.82
|
| Rate for Payer: Aetna of IA Medicare |
$15.72
|
| Rate for Payer: Amerigroup Medicaid |
$15.91
|
| Rate for Payer: Amerigroup Medicare |
$12.53
|
| Rate for Payer: Cash Price |
$22.06
|
| Rate for Payer: Cash Price |
$22.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.75
|
| Rate for Payer: Medical Associates Commercial |
$20.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.41
|
| Rate for Payer: Midlands Choice Commercial |
$19.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.27
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.27
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
gentamicin 40 mg/mL 20ml Inj Sol [VDMC]
|
Facility
|
OP
|
$110.91
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391760
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.91 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$99.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.82
|
| Rate for Payer: Aetna of IA Medicare |
$63.22
|
| Rate for Payer: Amerigroup Medicaid |
$63.97
|
| Rate for Payer: Amerigroup Medicare |
$50.41
|
| Rate for Payer: Cash Price |
$88.73
|
| Rate for Payer: Cash Price |
$88.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$63.35
|
| Rate for Payer: Medical Associates Commercial |
$83.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.91
|
| Rate for Payer: Midlands Choice Commercial |
$77.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$64.29
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.40
|
| Rate for Payer: United Healthcare Commercial |
$99.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.44
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
gentamicin 40 mg/mL 20ml Inj Sol [VDMC]
|
Facility
|
IP
|
$110.91
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391760
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$77.64 |
| Max. Negotiated Rate |
$99.82 |
| Rate for Payer: Aetna of IA Commercial |
$99.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.82
|
| Rate for Payer: Cash Price |
$88.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.19
|
| Rate for Payer: Medical Associates Commercial |
$83.19
|
| Rate for Payer: Midlands Choice Commercial |
$77.64
|
| Rate for Payer: United Healthcare Commercial |
$99.82
|
|
|
gentamicin 80 mg/100 mL-NS IV Sol [VDMC]
|
Facility
|
OP
|
$57.33
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391831
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.80 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$51.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.60
|
| Rate for Payer: Aetna of IA Medicare |
$32.68
|
| Rate for Payer: Amerigroup Medicaid |
$33.07
|
| Rate for Payer: Amerigroup Medicare |
$26.06
|
| Rate for Payer: Cash Price |
$45.87
|
| Rate for Payer: Cash Price |
$45.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$25.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.75
|
| Rate for Payer: Medical Associates Commercial |
$43.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.80
|
| Rate for Payer: Midlands Choice Commercial |
$40.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$29.67
|
| Rate for Payer: United Healthcare Commercial |
$51.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.83
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
gentamicin 80 mg/100 mL-NS IV Sol [VDMC]
|
Facility
|
IP
|
$57.33
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391831
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.13 |
| Max. Negotiated Rate |
$51.60 |
| Rate for Payer: Aetna of IA Commercial |
$51.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.60
|
| Rate for Payer: Cash Price |
$45.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.00
|
| Rate for Payer: Medical Associates Commercial |
$43.00
|
| Rate for Payer: Midlands Choice Commercial |
$40.13
|
| Rate for Payer: United Healthcare Commercial |
$51.60
|
|
|
gentamicin Ophth 0.3% Sol 5ml Bottle [VDMC]
|
Facility
|
IP
|
$27.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434650
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.24 |
| Max. Negotiated Rate |
$24.73 |
| Rate for Payer: Aetna of IA Commercial |
$24.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.73
|
| Rate for Payer: Cash Price |
$21.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.61
|
| Rate for Payer: Medical Associates Commercial |
$20.61
|
| Rate for Payer: Midlands Choice Commercial |
$19.24
|
| Rate for Payer: United Healthcare Commercial |
$24.73
|
|
|
gentamicin Ophth 0.3% Sol 5ml Bottle [VDMC]
|
Facility
|
OP
|
$27.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434650
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.37 |
| Max. Negotiated Rate |
$24.73 |
| Rate for Payer: Aetna of IA Commercial |
$24.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.73
|
| Rate for Payer: Aetna of IA Medicare |
$15.66
|
| Rate for Payer: Amerigroup Medicaid |
$15.85
|
| Rate for Payer: Amerigroup Medicare |
$12.49
|
| Rate for Payer: Cash Price |
$21.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.61
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.37
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.70
|
| Rate for Payer: Medical Associates Commercial |
$20.61
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.37
|
| Rate for Payer: Midlands Choice Commercial |
$19.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.22
|
| Rate for Payer: United Healthcare Commercial |
$24.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.21
|
|
|
GENTAMYCIN LEVEL
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633736
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of IA Commercial |
$100.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.80
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.00
|
| Rate for Payer: Medical Associates Commercial |
$84.00
|
| Rate for Payer: Midlands Choice Commercial |
$78.40
|
| Rate for Payer: United Healthcare Commercial |
$100.80
|
|
|
GENTAMYCIN LEVEL
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633735
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of IA Commercial |
$100.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.80
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.00
|
| Rate for Payer: Medical Associates Commercial |
$84.00
|
| Rate for Payer: Midlands Choice Commercial |
$78.40
|
| Rate for Payer: United Healthcare Commercial |
$100.80
|
|
|
GENTAMYCIN LEVEL
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633735
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of IA Commercial |
$100.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.80
|
| Rate for Payer: Aetna of IA Medicare |
$63.84
|
| Rate for Payer: Amerigroup Medicaid |
$64.60
|
| Rate for Payer: Amerigroup Medicare |
$50.90
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$50.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$63.97
|
| Rate for Payer: Medical Associates Commercial |
$84.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$50.40
|
| Rate for Payer: Midlands Choice Commercial |
$78.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$64.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.96
|
| Rate for Payer: United Healthcare Commercial |
$100.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$66.08
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
GENTAMYCIN LEVEL
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633736
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of IA Commercial |
$100.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.80
|
| Rate for Payer: Aetna of IA Medicare |
$63.84
|
| Rate for Payer: Amerigroup Medicaid |
$64.60
|
| Rate for Payer: Amerigroup Medicare |
$50.90
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$50.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$63.97
|
| Rate for Payer: Medical Associates Commercial |
$84.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$50.40
|
| Rate for Payer: Midlands Choice Commercial |
$78.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$64.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.96
|
| Rate for Payer: United Healthcare Commercial |
$100.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$66.08
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
gentian violet 1% topical solution [VDMC]
|
Facility
|
OP
|
$19.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11340289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna of IA Commercial |
$17.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$17.32
|
| Rate for Payer: Aetna of IA Medicare |
$10.97
|
| Rate for Payer: Amerigroup Medicaid |
$11.10
|
| Rate for Payer: Amerigroup Medicare |
$8.74
|
| Rate for Payer: Cash Price |
$15.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.99
|
| Rate for Payer: Medical Associates Commercial |
$14.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.66
|
| Rate for Payer: Midlands Choice Commercial |
$13.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.96
|
| Rate for Payer: United Healthcare Commercial |
$17.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.35
|
|
|
gentian violet 1% topical solution [VDMC]
|
Facility
|
IP
|
$19.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11340289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.47 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna of IA Commercial |
$17.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$17.32
|
| Rate for Payer: Cash Price |
$15.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.43
|
| Rate for Payer: Medical Associates Commercial |
$14.43
|
| Rate for Payer: Midlands Choice Commercial |
$13.47
|
| Rate for Payer: United Healthcare Commercial |
$17.32
|
|
|
GESTATIONAL DIAB ED INDIV T19
|
Facility
|
IP
|
$1,255.00
|
|
|
Service Code
|
HCPCS S9455
|
| Hospital Charge Code |
8059034
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$878.50 |
| Max. Negotiated Rate |
$1,129.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,129.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,129.50
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$941.25
|
| Rate for Payer: Medical Associates Commercial |
$941.25
|
| Rate for Payer: Midlands Choice Commercial |
$878.50
|
| Rate for Payer: United Healthcare Commercial |
$1,129.50
|
|
|
GESTATIONAL DIAB ED INDIV T19
|
Facility
|
OP
|
$1,255.00
|
|
|
Service Code
|
HCPCS S9455
|
| Hospital Charge Code |
8059034
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$102.10 |
| Max. Negotiated Rate |
$1,129.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,129.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,129.50
|
| Rate for Payer: Aetna of IA Medicare |
$715.35
|
| Rate for Payer: Amerigroup Medicaid |
$723.88
|
| Rate for Payer: Amerigroup Medicare |
$570.40
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$941.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$564.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$716.86
|
| Rate for Payer: Medical Associates Commercial |
$941.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$564.75
|
| Rate for Payer: Midlands Choice Commercial |
$878.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$727.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$649.46
|
| Rate for Payer: United Healthcare Commercial |
$1,129.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$740.45
|
| Rate for Payer: Wellmark IA HMO WHPI |
$102.10
|
| Rate for Payer: Wellmark IA PPO |
$112.46
|
|
|
GGTP (GAMMA-GLUT)
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
1628895
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$30.49 |
| Max. Negotiated Rate |
$62.10 |
| Rate for Payer: Aetna of IA Commercial |
$62.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$62.10
|
| Rate for Payer: Aetna of IA Medicare |
$39.33
|
| Rate for Payer: Amerigroup Medicaid |
$39.80
|
| Rate for Payer: Amerigroup Medicare |
$31.36
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$51.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$39.41
|
| Rate for Payer: Medical Associates Commercial |
$51.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.05
|
| Rate for Payer: Midlands Choice Commercial |
$48.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$39.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$35.71
|
| Rate for Payer: United Healthcare Commercial |
$62.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$40.71
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
GGTP (GAMMA-GLUT)
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
1628895
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$62.10 |
| Rate for Payer: Aetna of IA Commercial |
$62.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$62.10
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$51.75
|
| Rate for Payer: Medical Associates Commercial |
$51.75
|
| Rate for Payer: Midlands Choice Commercial |
$48.30
|
| Rate for Payer: United Healthcare Commercial |
$62.10
|
|
|
Giardia Antigen
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 87329
|
| Hospital Charge Code |
8059691
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
