|
L-Carnitine 500mg [VDMC]
|
Facility
|
OP
|
$2.62
|
|
|
Service Code
|
HCPCS A9720
|
| Hospital Charge Code |
23410802
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna of IA Commercial |
$2.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.36
|
| Rate for Payer: Aetna of IA Medicare |
$1.50
|
| Rate for Payer: Amerigroup Medicaid |
$1.51
|
| Rate for Payer: Amerigroup Medicare |
$1.19
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.18
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.50
|
| Rate for Payer: Medical Associates Commercial |
$1.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.18
|
| Rate for Payer: Midlands Choice Commercial |
$1.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$2.36
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.55
|
|
|
LD COMP W/FORC/VAC/3RD-4TH DEG LAC EPIS
|
Facility
|
IP
|
$2,505.00
|
|
|
Service Code
|
CPT 59409
|
| Hospital Charge Code |
7984736
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,753.50 |
| Max. Negotiated Rate |
$2,254.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,254.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,254.50
|
| Rate for Payer: Cash Price |
$2,004.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,878.75
|
| Rate for Payer: Medical Associates Commercial |
$1,878.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,753.50
|
| Rate for Payer: United Healthcare Commercial |
$2,254.50
|
|
|
LD COMP W/FORC/VAC/3RD-4TH DEG LAC EPIS
|
Facility
|
OP
|
$2,505.00
|
|
|
Service Code
|
CPT 59409
|
| Hospital Charge Code |
7984736
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,127.25 |
| Max. Negotiated Rate |
$2,254.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,254.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,254.50
|
| Rate for Payer: Aetna of IA Medicare |
$1,427.85
|
| Rate for Payer: Amerigroup Medicaid |
$1,444.88
|
| Rate for Payer: Amerigroup Medicare |
$1,138.52
|
| Rate for Payer: Cash Price |
$2,004.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,878.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,127.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,430.86
|
| Rate for Payer: Medical Associates Commercial |
$1,878.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,127.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,753.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,451.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,296.34
|
| Rate for Payer: United Healthcare Commercial |
$2,254.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,477.95
|
|
|
LDH
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 83615
|
| Hospital Charge Code |
4022826
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
|
|
LDH
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 83615
|
| Hospital Charge Code |
633770
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
|
|
LDH
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 83615
|
| Hospital Charge Code |
4022826
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Aetna of IA Medicare |
$33.06
|
| Rate for Payer: Amerigroup Medicaid |
$33.45
|
| Rate for Payer: Amerigroup Medicare |
$26.36
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.13
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.10
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.02
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.22
|
|
|
LDH
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 83615
|
| Hospital Charge Code |
633770
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Aetna of IA Medicare |
$33.06
|
| Rate for Payer: Amerigroup Medicaid |
$33.45
|
| Rate for Payer: Amerigroup Medicare |
$26.36
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.13
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.10
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.02
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.22
|
|
|
LD W/O COMPLICATIONS 1ST-2ND DEG LAC
|
Facility
|
OP
|
$1,490.00
|
|
|
Service Code
|
CPT 59409
|
| Hospital Charge Code |
7984737
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$670.50 |
| Max. Negotiated Rate |
$1,341.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,341.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,341.00
|
| Rate for Payer: Aetna of IA Medicare |
$849.30
|
| Rate for Payer: Amerigroup Medicaid |
$859.43
|
| Rate for Payer: Amerigroup Medicare |
$677.21
|
| Rate for Payer: Cash Price |
$1,192.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,117.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$670.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$851.09
|
| Rate for Payer: Medical Associates Commercial |
$1,117.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$670.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,043.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$863.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$771.08
|
| Rate for Payer: United Healthcare Commercial |
$1,341.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$879.10
|
|
|
LD W/O COMPLICATIONS 1ST-2ND DEG LAC
|
Facility
|
IP
|
$1,490.00
|
|
|
Service Code
|
CPT 59409
|
| Hospital Charge Code |
7984737
|
|
Hospital Revenue Code
|
722
|
| Min. Negotiated Rate |
$1,043.00 |
| Max. Negotiated Rate |
$1,341.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,341.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,341.00
|
| Rate for Payer: Cash Price |
$1,192.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,117.50
|
| Rate for Payer: Medical Associates Commercial |
$1,117.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,043.00
|
| Rate for Payer: United Healthcare Commercial |
$1,341.00
|
|
|
LEAD
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
8094268
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
LEAD
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
8094268
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.90 |
| 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: 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
|
|
|
Lead Level Screen
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
8487747
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.90 |
| 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: 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
|
|
|
Lead Level Screen
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
8487747
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
Lead Level Screen DMCL
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
8037723
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.90 |
| 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: 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
|
|
|
Lead Level Screen DMCL
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
8037723
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
leflunomide 20 mg Tab [VDMC]
|
Facility
|
OP
|
$2.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399163
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Aetna of IA Commercial |
$2.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.63
|
| Rate for Payer: Aetna of IA Medicare |
$1.67
|
| Rate for Payer: Amerigroup Medicaid |
$1.69
|
| Rate for Payer: Amerigroup Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.67
|
| Rate for Payer: Medical Associates Commercial |
$2.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.31
|
| Rate for Payer: Midlands Choice Commercial |
$2.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$2.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.72
|
|
|
leflunomide 20 mg Tab [VDMC]
|
Facility
|
IP
|
$2.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399163
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Aetna of IA Commercial |
$2.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.63
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.19
|
| Rate for Payer: Medical Associates Commercial |
$2.19
|
| Rate for Payer: Midlands Choice Commercial |
$2.04
|
| Rate for Payer: United Healthcare Commercial |
$2.63
|
|
|
Legionella Antigen DMCL
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 87449
|
| Hospital Charge Code |
8037724
|
|
Hospital Revenue Code
|
302
|
| 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
|
|
|
Legionella Antigen DMCL
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 87449
|
| Hospital Charge Code |
8037724
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$51.30 |
| 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: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$65.76
|
| Rate for Payer: Amerigroup Medicare |
$51.81
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.12
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.30
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$58.99
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
|
|
LENS 10.0
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
8047304
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$121.50 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$155.74
|
| Rate for Payer: Amerigroup Medicare |
$122.72
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$121.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$154.22
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$121.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$156.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$139.72
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
LENS 10.0
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
8047304
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
LENS 10.0 CNW0T4.100
|
Facility
|
OP
|
$375.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
8972634
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$168.75 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Aetna of IA Commercial |
$337.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$337.50
|
| Rate for Payer: Aetna of IA Medicare |
$213.75
|
| Rate for Payer: Amerigroup Medicaid |
$216.30
|
| Rate for Payer: Amerigroup Medicare |
$170.44
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$281.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$168.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$214.20
|
| Rate for Payer: Medical Associates Commercial |
$281.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$168.75
|
| Rate for Payer: Midlands Choice Commercial |
$262.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$217.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$194.06
|
| Rate for Payer: United Healthcare Commercial |
$337.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$221.25
|
|
|
LENS 10.0 CNW0T4.100
|
Facility
|
IP
|
$375.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
8972634
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Aetna of IA Commercial |
$337.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$337.50
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$281.25
|
| Rate for Payer: Medical Associates Commercial |
$281.25
|
| Rate for Payer: Midlands Choice Commercial |
$262.50
|
| Rate for Payer: United Healthcare Commercial |
$337.50
|
|
|
LENS 10.0 CNWET0.100
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
8965705
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$393.75 |
| Max. Negotiated Rate |
$787.50 |
| Rate for Payer: Aetna of IA Commercial |
$787.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$787.50
|
| Rate for Payer: Aetna of IA Medicare |
$498.75
|
| Rate for Payer: Amerigroup Medicaid |
$504.70
|
| Rate for Payer: Amerigroup Medicare |
$397.69
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$656.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$393.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$499.80
|
| Rate for Payer: Medical Associates Commercial |
$656.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$393.75
|
| Rate for Payer: Midlands Choice Commercial |
$612.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$507.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$452.81
|
| Rate for Payer: United Healthcare Commercial |
$787.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$516.25
|
|
|
LENS 10.0 CNWET0.100
|
Facility
|
IP
|
$875.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
8965705
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$612.50 |
| Max. Negotiated Rate |
$787.50 |
| Rate for Payer: Aetna of IA Commercial |
$787.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$787.50
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$656.25
|
| Rate for Payer: Medical Associates Commercial |
$656.25
|
| Rate for Payer: Midlands Choice Commercial |
$612.50
|
| Rate for Payer: United Healthcare Commercial |
$787.50
|
|
