inFLIXimab-dyyb 100 mg Pow SDV [VDMC]
|
Facility
|
OP
|
$1,016.76
|
|
Service Code
|
HCPCS Q5103
|
Hospital Charge Code |
20049518
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$457.54 |
Max. Negotiated Rate |
$915.08 |
Rate for Payer: Aetna of IA Commercial |
$915.08
|
Rate for Payer: Aetna of IA Medical Rental Products |
$915.08
|
Rate for Payer: Aetna of IA Medicare |
$579.55
|
Rate for Payer: Amerigroup Medicaid |
$586.47
|
Rate for Payer: Amerigroup Medicare |
$462.12
|
Rate for Payer: Cash Price |
$813.41
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$762.57
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$457.54
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$580.77
|
Rate for Payer: Medical Associates Commercial |
$762.57
|
Rate for Payer: Medical Associates Managed Medicare |
$457.54
|
Rate for Payer: Midlands Choice Commercial |
$711.73
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$589.31
|
Rate for Payer: Partners Health Alliance Commercial |
$526.17
|
Rate for Payer: United Healthcare Commercial |
$915.08
|
Rate for Payer: United Healthcare Managed Medicare |
$599.89
|
|
INFLUENZA AB
|
Facility
|
OP
|
$82.00
|
|
Service Code
|
CPT 87804
|
Hospital Charge Code |
4110785
|
Hospital Revenue Code
|
306
|
Min. Negotiated Rate |
$34.03 |
Max. Negotiated Rate |
$73.80 |
Rate for Payer: Aetna of IA Commercial |
$73.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
Rate for Payer: Aetna of IA Medicare |
$46.74
|
Rate for Payer: Amerigroup Medicaid |
$47.30
|
Rate for Payer: Amerigroup Medicare |
$37.27
|
Rate for Payer: Cash Price |
$65.60
|
Rate for Payer: Cash Price |
$65.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$36.90
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$46.84
|
Rate for Payer: Medical Associates Commercial |
$61.50
|
Rate for Payer: Medical Associates Managed Medicare |
$36.90
|
Rate for Payer: Midlands Choice Commercial |
$57.40
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$47.53
|
Rate for Payer: Partners Health Alliance Commercial |
$42.44
|
Rate for Payer: United Healthcare Commercial |
$73.80
|
Rate for Payer: United Healthcare Managed Medicare |
$48.38
|
Rate for Payer: Wellmark IA HMO WHPI |
$34.03
|
Rate for Payer: Wellmark IA PPO |
$37.49
|
|
INFLUENZA AB
|
Facility
|
IP
|
$82.00
|
|
Service Code
|
CPT 87804
|
Hospital Charge Code |
4110785
|
Hospital Revenue Code
|
306
|
Min. Negotiated Rate |
$57.40 |
Max. Negotiated Rate |
$73.80 |
Rate for Payer: Aetna of IA Commercial |
$73.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
Rate for Payer: Cash Price |
$65.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
Rate for Payer: Medical Associates Commercial |
$61.50
|
Rate for Payer: Midlands Choice Commercial |
$57.40
|
Rate for Payer: United Healthcare Commercial |
$73.80
|
|
influenza HD virus vaccine, inactivated adjuvanted preservative-free trivalent Sus UD[VDMC]
|
Facility
|
OP
|
$121.68
|
|
Service Code
|
HCPCS 90653
|
Hospital Charge Code |
28497053
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$54.76 |
Max. Negotiated Rate |
$109.51 |
Rate for Payer: Aetna of IA Commercial |
$109.51
|
Rate for Payer: Aetna of IA Medical Rental Products |
$109.51
|
Rate for Payer: Aetna of IA Medicare |
$69.36
|
Rate for Payer: Amerigroup Medicaid |
$70.19
|
Rate for Payer: Amerigroup Medicare |
$55.30
|
Rate for Payer: Cash Price |
$97.34
|
Rate for Payer: Cash Price |
$97.34
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$91.26
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.76
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$69.50
|
Rate for Payer: Medical Associates Commercial |
$91.26
|
Rate for Payer: Medical Associates Managed Medicare |
$54.76
|
Rate for Payer: Midlands Choice Commercial |
$85.18
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$70.53
|
Rate for Payer: Partners Health Alliance Commercial |
$62.97
|
Rate for Payer: United Healthcare Commercial |
$109.51
|
Rate for Payer: United Healthcare Managed Medicare |
$71.79
|
Rate for Payer: Wellmark IA HMO WHPI |
$80.12
|
Rate for Payer: Wellmark IA PPO |
$88.25
|
|
influenza HD virus vaccine, inactivated adjuvanted preservative-free trivalent Sus UD[VDMC]
|
Facility
|
IP
|
$121.68
|
|
Service Code
|
HCPCS 90653
|
Hospital Charge Code |
28497053
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$85.18 |
Max. Negotiated Rate |
$109.51 |
Rate for Payer: Aetna of IA Commercial |
$109.51
|
Rate for Payer: Aetna of IA Medical Rental Products |
$109.51
|
Rate for Payer: Cash Price |
$97.34
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$91.26
|
Rate for Payer: Medical Associates Commercial |
$91.26
|
Rate for Payer: Midlands Choice Commercial |
$85.18
|
Rate for Payer: United Healthcare Commercial |
$109.51
|
|
influenza TRI Syringe virus vaccine, inactivated preservative-free trivalent Sus[VDMC]
|
Facility
|
OP
|
$31.00
|
|
Service Code
|
HCPCS 90656
|
Hospital Charge Code |
28463286
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$13.95 |
Max. Negotiated Rate |
$88.25 |
Rate for Payer: Aetna of IA Commercial |
$27.90
|
Rate for Payer: Aetna of IA Medical Rental Products |
$27.90
|
Rate for Payer: Aetna of IA Medicare |
$17.67
|
Rate for Payer: Amerigroup Medicaid |
$17.88
|
Rate for Payer: Amerigroup Medicare |
$14.09
|
Rate for Payer: Cash Price |
$24.80
|
Rate for Payer: Cash Price |
$24.80
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.25
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.95
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$17.71
|
Rate for Payer: Medical Associates Commercial |
$23.25
|
Rate for Payer: Medical Associates Managed Medicare |
$13.95
|
Rate for Payer: Midlands Choice Commercial |
$21.70
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$17.97
|
Rate for Payer: Partners Health Alliance Commercial |
$16.04
|
Rate for Payer: United Healthcare Commercial |
$27.90
|
Rate for Payer: United Healthcare Managed Medicare |
$18.29
|
Rate for Payer: Wellmark IA HMO WHPI |
$80.12
|
Rate for Payer: Wellmark IA PPO |
$88.25
|
|
influenza TRI Syringe virus vaccine, inactivated preservative-free trivalent Sus[VDMC]
|
Facility
|
IP
|
$31.00
|
|
Service Code
|
HCPCS 90656
|
Hospital Charge Code |
28463286
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$21.70 |
Max. Negotiated Rate |
$27.90 |
Rate for Payer: Aetna of IA Commercial |
$27.90
|
Rate for Payer: Aetna of IA Medical Rental Products |
$27.90
|
Rate for Payer: Cash Price |
$24.80
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.25
|
Rate for Payer: Medical Associates Commercial |
$23.25
|
Rate for Payer: Midlands Choice Commercial |
$21.70
|
Rate for Payer: United Healthcare Commercial |
$27.90
|
|
INF TX-CONCURRENT
|
Facility
|
OP
|
$103.00
|
|
Service Code
|
CPT 96368
|
Hospital Charge Code |
4866839
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$46.35 |
Max. Negotiated Rate |
$598.25 |
Rate for Payer: Aetna of IA Commercial |
$92.70
|
Rate for Payer: Aetna of IA Medical Rental Products |
$92.70
|
Rate for Payer: Aetna of IA Medicare |
$58.71
|
Rate for Payer: Amerigroup Medicaid |
$59.41
|
Rate for Payer: Amerigroup Medicare |
$46.81
|
Rate for Payer: Cash Price |
$82.40
|
Rate for Payer: Cash Price |
$82.40
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$77.25
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$46.35
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$58.83
|
Rate for Payer: Medical Associates Commercial |
$77.25
|
Rate for Payer: Medical Associates Managed Medicare |
$46.35
|
Rate for Payer: Midlands Choice Commercial |
$72.10
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$59.70
|
Rate for Payer: Partners Health Alliance Commercial |
$53.30
|
Rate for Payer: United Healthcare Commercial |
$92.70
|
Rate for Payer: United Healthcare Managed Medicare |
$60.77
|
Rate for Payer: Wellmark IA HMO WHPI |
$543.09
|
Rate for Payer: Wellmark IA PPO |
$598.25
|
|
INF TX-CONCURRENT
|
Facility
|
IP
|
$103.00
|
|
Service Code
|
CPT 96368
|
Hospital Charge Code |
4866839
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$72.10 |
Max. Negotiated Rate |
$92.70 |
Rate for Payer: Aetna of IA Commercial |
$92.70
|
Rate for Payer: Aetna of IA Medical Rental Products |
$92.70
|
Rate for Payer: Cash Price |
$82.40
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$77.25
|
Rate for Payer: Medical Associates Commercial |
$77.25
|
Rate for Payer: Midlands Choice Commercial |
$72.10
|
Rate for Payer: United Healthcare Commercial |
$92.70
|
|
INF TX-CONCURRENT
|
Facility
|
OP
|
$103.00
|
|
Service Code
|
CPT 96368
|
Hospital Charge Code |
6922818
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$46.35 |
Max. Negotiated Rate |
$598.25 |
Rate for Payer: Aetna of IA Commercial |
$92.70
|
Rate for Payer: Aetna of IA Medical Rental Products |
$92.70
|
Rate for Payer: Aetna of IA Medicare |
$58.71
|
Rate for Payer: Amerigroup Medicaid |
$59.41
|
Rate for Payer: Amerigroup Medicare |
$46.81
|
Rate for Payer: Cash Price |
$82.40
|
Rate for Payer: Cash Price |
$82.40
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$77.25
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$46.35
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$58.83
|
Rate for Payer: Medical Associates Commercial |
$77.25
|
Rate for Payer: Medical Associates Managed Medicare |
$46.35
|
Rate for Payer: Midlands Choice Commercial |
$72.10
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$59.70
|
Rate for Payer: Partners Health Alliance Commercial |
$53.30
|
Rate for Payer: United Healthcare Commercial |
$92.70
|
Rate for Payer: United Healthcare Managed Medicare |
$60.77
|
Rate for Payer: Wellmark IA HMO WHPI |
$543.09
|
Rate for Payer: Wellmark IA PPO |
$598.25
|
|
INF TX-CONCURRENT
|
Facility
|
IP
|
$103.00
|
|
Service Code
|
CPT 96368
|
Hospital Charge Code |
6922818
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$72.10 |
Max. Negotiated Rate |
$92.70 |
Rate for Payer: Aetna of IA Commercial |
$92.70
|
Rate for Payer: Aetna of IA Medical Rental Products |
$92.70
|
Rate for Payer: Cash Price |
$82.40
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$77.25
|
Rate for Payer: Medical Associates Commercial |
$77.25
|
Rate for Payer: Midlands Choice Commercial |
$72.10
|
Rate for Payer: United Healthcare Commercial |
$92.70
|
|
INF TX HYDRATION 1ST HR
|
Facility
|
OP
|
$344.00
|
|
Service Code
|
CPT 96360
|
Hospital Charge Code |
6922793
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$154.80 |
Max. Negotiated Rate |
$598.25 |
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 |
$543.09
|
Rate for Payer: Wellmark IA PPO |
$598.25
|
|
INF TX HYDRATION 1ST HR
|
Facility
|
IP
|
$344.00
|
|
Service Code
|
CPT 96360
|
Hospital Charge Code |
6922793
|
Hospital Revenue Code
|
260
|
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
|
|
INF TX HYDRATION 1ST HR
|
Facility
|
IP
|
$344.00
|
|
Service Code
|
CPT 96360
|
Hospital Charge Code |
4866847
|
Hospital Revenue Code
|
260
|
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
|
|
INF TX HYDRATION 1ST HR
|
Facility
|
OP
|
$344.00
|
|
Service Code
|
CPT 96360
|
Hospital Charge Code |
4866847
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$154.80 |
Max. Negotiated Rate |
$598.25 |
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 |
$543.09
|
Rate for Payer: Wellmark IA PPO |
$598.25
|
|
INF TX HYDRATION EA ADDL HR
|
Facility
|
IP
|
$152.00
|
|
Service Code
|
CPT 96361
|
Hospital Charge Code |
6922794
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$106.40 |
Max. Negotiated Rate |
$136.80 |
Rate for Payer: Aetna of IA Commercial |
$136.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$136.80
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.00
|
Rate for Payer: Medical Associates Commercial |
$114.00
|
Rate for Payer: Midlands Choice Commercial |
$106.40
|
Rate for Payer: United Healthcare Commercial |
$136.80
|
|
INF TX HYDRATION EA ADDL HR
|
Facility
|
OP
|
$152.00
|
|
Service Code
|
CPT 96361
|
Hospital Charge Code |
6922794
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$68.40 |
Max. Negotiated Rate |
$690.40 |
Rate for Payer: Aetna of IA Commercial |
$136.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$136.80
|
Rate for Payer: Aetna of IA Medicare |
$86.64
|
Rate for Payer: Amerigroup Medicaid |
$87.67
|
Rate for Payer: Amerigroup Medicare |
$69.08
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.00
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$68.40
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$86.82
|
Rate for Payer: Medical Associates Commercial |
$114.00
|
Rate for Payer: Medical Associates Managed Medicare |
$68.40
|
Rate for Payer: Midlands Choice Commercial |
$106.40
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$88.10
|
Rate for Payer: Partners Health Alliance Commercial |
$78.66
|
Rate for Payer: United Healthcare Commercial |
$136.80
|
Rate for Payer: United Healthcare Managed Medicare |
$89.68
|
Rate for Payer: Wellmark IA HMO WHPI |
$626.76
|
Rate for Payer: Wellmark IA PPO |
$690.40
|
|
INF TX HYDRATION EA ADDL HR
|
Facility
|
IP
|
$152.00
|
|
Service Code
|
CPT 96361
|
Hospital Charge Code |
4866845
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$106.40 |
Max. Negotiated Rate |
$136.80 |
Rate for Payer: Aetna of IA Commercial |
$136.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$136.80
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.00
|
Rate for Payer: Medical Associates Commercial |
$114.00
|
Rate for Payer: Midlands Choice Commercial |
$106.40
|
Rate for Payer: United Healthcare Commercial |
$136.80
|
|
INF TX HYDRATION EA ADDL HR
|
Facility
|
OP
|
$152.00
|
|
Service Code
|
CPT 96361
|
Hospital Charge Code |
4866845
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$68.40 |
Max. Negotiated Rate |
$690.40 |
Rate for Payer: Aetna of IA Commercial |
$136.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$136.80
|
Rate for Payer: Aetna of IA Medicare |
$86.64
|
Rate for Payer: Amerigroup Medicaid |
$87.67
|
Rate for Payer: Amerigroup Medicare |
$69.08
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.00
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$68.40
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$86.82
|
Rate for Payer: Medical Associates Commercial |
$114.00
|
Rate for Payer: Medical Associates Managed Medicare |
$68.40
|
Rate for Payer: Midlands Choice Commercial |
$106.40
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$88.10
|
Rate for Payer: Partners Health Alliance Commercial |
$78.66
|
Rate for Payer: United Healthcare Commercial |
$136.80
|
Rate for Payer: United Healthcare Managed Medicare |
$89.68
|
Rate for Payer: Wellmark IA HMO WHPI |
$626.76
|
Rate for Payer: Wellmark IA PPO |
$690.40
|
|
INF TX HYDRATION-SCHED 1ST HR
|
Facility
|
OP
|
$344.00
|
|
Service Code
|
CPT 96360
|
Hospital Charge Code |
8012935
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$154.80 |
Max. Negotiated Rate |
$598.25 |
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 |
$543.09
|
Rate for Payer: Wellmark IA PPO |
$598.25
|
|
INF TX HYDRATION-SCHED 1ST HR
|
Facility
|
IP
|
$344.00
|
|
Service Code
|
CPT 96360
|
Hospital Charge Code |
8012935
|
Hospital Revenue Code
|
260
|
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
|
|
INF TX HYDR SCHED EA ADDL HR
|
Facility
|
IP
|
$152.00
|
|
Service Code
|
CPT 96361
|
Hospital Charge Code |
8012936
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$106.40 |
Max. Negotiated Rate |
$136.80 |
Rate for Payer: Aetna of IA Commercial |
$136.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$136.80
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.00
|
Rate for Payer: Medical Associates Commercial |
$114.00
|
Rate for Payer: Midlands Choice Commercial |
$106.40
|
Rate for Payer: United Healthcare Commercial |
$136.80
|
|
INF TX HYDR SCHED EA ADDL HR
|
Facility
|
OP
|
$152.00
|
|
Service Code
|
CPT 96361
|
Hospital Charge Code |
8012936
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$68.40 |
Max. Negotiated Rate |
$690.40 |
Rate for Payer: Aetna of IA Commercial |
$136.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$136.80
|
Rate for Payer: Aetna of IA Medicare |
$86.64
|
Rate for Payer: Amerigroup Medicaid |
$87.67
|
Rate for Payer: Amerigroup Medicare |
$69.08
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Cash Price |
$121.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.00
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$68.40
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$86.82
|
Rate for Payer: Medical Associates Commercial |
$114.00
|
Rate for Payer: Medical Associates Managed Medicare |
$68.40
|
Rate for Payer: Midlands Choice Commercial |
$106.40
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$88.10
|
Rate for Payer: Partners Health Alliance Commercial |
$78.66
|
Rate for Payer: United Healthcare Commercial |
$136.80
|
Rate for Payer: United Healthcare Managed Medicare |
$89.68
|
Rate for Payer: Wellmark IA HMO WHPI |
$626.76
|
Rate for Payer: Wellmark IA PPO |
$690.40
|
|
INF TX MED 1ST HR
|
Facility
|
IP
|
$382.00
|
|
Service Code
|
CPT 96365
|
Hospital Charge Code |
4866843
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$267.40 |
Max. Negotiated Rate |
$343.80 |
Rate for Payer: Aetna of IA Commercial |
$343.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$343.80
|
Rate for Payer: Cash Price |
$305.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$286.50
|
Rate for Payer: Medical Associates Commercial |
$286.50
|
Rate for Payer: Midlands Choice Commercial |
$267.40
|
Rate for Payer: United Healthcare Commercial |
$343.80
|
|
INF TX MED 1ST HR
|
Facility
|
OP
|
$382.00
|
|
Service Code
|
CPT 96365
|
Hospital Charge Code |
4866843
|
Hospital Revenue Code
|
260
|
Min. Negotiated Rate |
$171.90 |
Max. Negotiated Rate |
$598.25 |
Rate for Payer: Aetna of IA Commercial |
$343.80
|
Rate for Payer: Aetna of IA Medical Rental Products |
$343.80
|
Rate for Payer: Aetna of IA Medicare |
$217.74
|
Rate for Payer: Amerigroup Medicaid |
$220.34
|
Rate for Payer: Amerigroup Medicare |
$173.62
|
Rate for Payer: Cash Price |
$305.60
|
Rate for Payer: Cash Price |
$305.60
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$286.50
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$171.90
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$218.20
|
Rate for Payer: Medical Associates Commercial |
$286.50
|
Rate for Payer: Medical Associates Managed Medicare |
$171.90
|
Rate for Payer: Midlands Choice Commercial |
$267.40
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$221.41
|
Rate for Payer: Partners Health Alliance Commercial |
$197.68
|
Rate for Payer: United Healthcare Commercial |
$343.80
|
Rate for Payer: United Healthcare Managed Medicare |
$225.38
|
Rate for Payer: Wellmark IA HMO WHPI |
$543.09
|
Rate for Payer: Wellmark IA PPO |
$598.25
|
|