|
leucovorin 200 mg SDV Pow
|
Facility
OP
|
$86.92
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
43700528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$78.23 |
| Rate for Payer: Aetna of IA Commercial |
$78.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$78.23
|
| Rate for Payer: Aetna of IA Medicare |
$49.54
|
| Rate for Payer: Amerigroup Medicaid |
$43.87
|
| Rate for Payer: Amerigroup Medicare |
$43.89
|
| Rate for Payer: Cash Price |
$69.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$43.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$43.44
|
| Rate for Payer: Medical Associates Commercial |
$65.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$43.46
|
| Rate for Payer: Midlands Choice Commercial |
$60.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$44.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$65.19
|
| Rate for Payer: United Healthcare Commercial |
$78.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$51.28
|
|
|
leucovorin 200 mg SDV Pow
|
Facility
IP
|
$86.92
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
43700528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.84 |
| Max. Negotiated Rate |
$78.23 |
| Rate for Payer: Aetna of IA Commercial |
$78.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$78.23
|
| Rate for Payer: Cash Price |
$69.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.19
|
| Rate for Payer: Medical Associates Commercial |
$65.19
|
| Rate for Payer: Midlands Choice Commercial |
$60.84
|
| Rate for Payer: United Healthcare Commercial |
$78.23
|
|
|
leucovorin 350 mg Pow SDV
|
Facility
OP
|
$95.68
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
43700356
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.82 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna of IA Commercial |
$86.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.11
|
| Rate for Payer: Aetna of IA Medicare |
$54.54
|
| Rate for Payer: Amerigroup Medicaid |
$48.29
|
| Rate for Payer: Amerigroup Medicare |
$48.32
|
| Rate for Payer: Cash Price |
$76.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$71.76
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$47.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$47.82
|
| Rate for Payer: Medical Associates Commercial |
$71.76
|
| Rate for Payer: Medical Associates Managed Medicare |
$47.84
|
| Rate for Payer: Midlands Choice Commercial |
$66.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$48.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$71.76
|
| Rate for Payer: United Healthcare Commercial |
$86.11
|
| Rate for Payer: United Healthcare Managed Medicare |
$56.45
|
|
|
leucovorin 350 mg Pow SDV
|
Facility
IP
|
$95.68
|
|
|
Service Code
|
CPT J0640
|
| Hospital Charge Code |
43700356
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.98 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna of IA Commercial |
$86.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.11
|
| Rate for Payer: Cash Price |
$76.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$71.76
|
| Rate for Payer: Medical Associates Commercial |
$71.76
|
| Rate for Payer: Midlands Choice Commercial |
$66.98
|
| Rate for Payer: United Healthcare Commercial |
$86.11
|
|
|
leuprolide 22.5 mg/3 months Pow
|
Facility
OP
|
$11,935.30
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
43700471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,965.26 |
| Max. Negotiated Rate |
$10,741.77 |
| Rate for Payer: Aetna of IA Commercial |
$10,741.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10,741.77
|
| Rate for Payer: Aetna of IA Medicare |
$6,803.12
|
| Rate for Payer: Amerigroup Medicaid |
$6,023.75
|
| Rate for Payer: Amerigroup Medicare |
$6,027.33
|
| Rate for Payer: Cash Price |
$9,548.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8,951.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5,967.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5,965.26
|
| Rate for Payer: Medical Associates Commercial |
$8,951.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$5,967.65
|
| Rate for Payer: Midlands Choice Commercial |
$8,354.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,057.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$8,951.48
|
| Rate for Payer: United Healthcare Commercial |
$10,741.77
|
| Rate for Payer: United Healthcare Managed Medicare |
$7,041.83
|
|
|
leuprolide 22.5 mg/3 months Pow
|
Facility
IP
|
$11,935.30
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
43700471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,354.71 |
| Max. Negotiated Rate |
$10,741.77 |
| Rate for Payer: Aetna of IA Commercial |
$10,741.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10,741.77
|
| Rate for Payer: Cash Price |
$9,548.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8,951.48
|
| Rate for Payer: Medical Associates Commercial |
$8,951.48
|
| Rate for Payer: Midlands Choice Commercial |
$8,354.71
|
| Rate for Payer: United Healthcare Commercial |
$10,741.77
|
|
|
leuprolide 30 mg/4 months Pow
|
Facility
OP
|
$10,856.72
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
43700139
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,426.19 |
| Max. Negotiated Rate |
$9,771.05 |
| Rate for Payer: Aetna of IA Commercial |
$9,771.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9,771.05
|
| Rate for Payer: Aetna of IA Medicare |
$6,188.33
|
| Rate for Payer: Amerigroup Medicaid |
$5,479.39
|
| Rate for Payer: Amerigroup Medicare |
$5,482.64
|
| Rate for Payer: Cash Price |
$8,685.38
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8,142.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5,428.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5,426.19
|
| Rate for Payer: Medical Associates Commercial |
$8,142.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$5,428.36
|
| Rate for Payer: Midlands Choice Commercial |
$7,599.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,509.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$8,142.54
|
| Rate for Payer: United Healthcare Commercial |
$9,771.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$6,405.46
|
|
|
leuprolide 30 mg/4 months Pow
|
Facility
IP
|
$10,856.72
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
43700139
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,599.70 |
| Max. Negotiated Rate |
$9,771.05 |
| Rate for Payer: Aetna of IA Commercial |
$9,771.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9,771.05
|
| Rate for Payer: Cash Price |
$8,685.38
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8,142.54
|
| Rate for Payer: Medical Associates Commercial |
$8,142.54
|
| Rate for Payer: Midlands Choice Commercial |
$7,599.70
|
| Rate for Payer: United Healthcare Commercial |
$9,771.05
|
|
|
leuprolide 3.75 mg/month Pow
|
Facility
OP
|
$3,410.62
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
43706695
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,704.63 |
| Max. Negotiated Rate |
$3,069.56 |
| Rate for Payer: Aetna of IA Commercial |
$3,069.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,069.56
|
| Rate for Payer: Aetna of IA Medicare |
$1,944.05
|
| Rate for Payer: Amerigroup Medicaid |
$1,721.34
|
| Rate for Payer: Amerigroup Medicare |
$1,722.36
|
| Rate for Payer: Cash Price |
$2,728.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,557.96
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,705.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,704.63
|
| Rate for Payer: Medical Associates Commercial |
$2,557.96
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,705.31
|
| Rate for Payer: Midlands Choice Commercial |
$2,387.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,730.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,557.96
|
| Rate for Payer: United Healthcare Commercial |
$3,069.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,012.27
|
|
|
leuprolide 3.75 mg/month Pow
|
Facility
IP
|
$3,410.62
|
|
|
Service Code
|
CPT J1950
|
| Hospital Charge Code |
43706695
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,387.43 |
| Max. Negotiated Rate |
$3,069.56 |
| Rate for Payer: Aetna of IA Commercial |
$3,069.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,069.56
|
| Rate for Payer: Cash Price |
$2,728.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,557.96
|
| Rate for Payer: Medical Associates Commercial |
$2,557.96
|
| Rate for Payer: Midlands Choice Commercial |
$2,387.43
|
| Rate for Payer: United Healthcare Commercial |
$3,069.56
|
|
|
leuprolide 45 mg/6 months Pow
|
Facility
IP
|
$14,914.52
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
43700481
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,440.16 |
| Max. Negotiated Rate |
$13,423.07 |
| Rate for Payer: Aetna of IA Commercial |
$13,423.07
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13,423.07
|
| Rate for Payer: Cash Price |
$11,931.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11,185.89
|
| Rate for Payer: Medical Associates Commercial |
$11,185.89
|
| Rate for Payer: Midlands Choice Commercial |
$10,440.16
|
| Rate for Payer: United Healthcare Commercial |
$13,423.07
|
|
|
leuprolide 45 mg/6 months Pow
|
Facility
OP
|
$14,914.52
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
43700481
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,454.28 |
| Max. Negotiated Rate |
$13,423.07 |
| Rate for Payer: Aetna of IA Commercial |
$13,423.07
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13,423.07
|
| Rate for Payer: Aetna of IA Medicare |
$8,501.28
|
| Rate for Payer: Amerigroup Medicaid |
$7,527.36
|
| Rate for Payer: Amerigroup Medicare |
$7,531.83
|
| Rate for Payer: Cash Price |
$11,931.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11,185.89
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7,457.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7,454.28
|
| Rate for Payer: Medical Associates Commercial |
$11,185.89
|
| Rate for Payer: Medical Associates Managed Medicare |
$7,457.26
|
| Rate for Payer: Midlands Choice Commercial |
$10,440.16
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,569.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$11,185.89
|
| Rate for Payer: United Healthcare Commercial |
$13,423.07
|
| Rate for Payer: United Healthcare Managed Medicare |
$8,799.57
|
|
|
leuprolide 7.5 mg/month IM Inj, ER
|
Facility
OP
|
$3,528.86
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
43709986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,763.72 |
| Max. Negotiated Rate |
$3,175.97 |
| Rate for Payer: Aetna of IA Commercial |
$3,175.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,175.97
|
| Rate for Payer: Aetna of IA Medicare |
$2,011.45
|
| Rate for Payer: Amerigroup Medicaid |
$1,781.02
|
| Rate for Payer: Amerigroup Medicare |
$1,782.07
|
| Rate for Payer: Cash Price |
$2,823.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,646.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,764.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,763.72
|
| Rate for Payer: Medical Associates Commercial |
$2,646.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,764.43
|
| Rate for Payer: Midlands Choice Commercial |
$2,470.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,790.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,646.64
|
| Rate for Payer: United Healthcare Commercial |
$3,175.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,082.03
|
|
|
leuprolide 7.5 mg/month IM Inj, ER
|
Facility
IP
|
$3,528.86
|
|
|
Service Code
|
CPT J9217
|
| Hospital Charge Code |
43709986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,470.20 |
| Max. Negotiated Rate |
$3,175.97 |
| Rate for Payer: Aetna of IA Commercial |
$3,175.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,175.97
|
| Rate for Payer: Cash Price |
$2,823.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,646.64
|
| Rate for Payer: Medical Associates Commercial |
$2,646.64
|
| Rate for Payer: Midlands Choice Commercial |
$2,470.20
|
| Rate for Payer: United Healthcare Commercial |
$3,175.97
|
|
|
levalbuterol 0.63 mg/3 mL neb Sol SDV
|
Facility
OP
|
$8.07
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706264
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$7.26 |
| Rate for Payer: Aetna of IA Commercial |
$7.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.26
|
| Rate for Payer: Aetna of IA Medicare |
$4.60
|
| Rate for Payer: Amerigroup Medicaid |
$4.07
|
| Rate for Payer: Amerigroup Medicare |
$4.08
|
| Rate for Payer: Cash Price |
$6.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.05
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.03
|
| Rate for Payer: Medical Associates Commercial |
$6.05
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.04
|
| Rate for Payer: Midlands Choice Commercial |
$5.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.05
|
| Rate for Payer: United Healthcare Commercial |
$7.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.76
|
|
|
levalbuterol 0.63 mg/3 mL neb Sol SDV
|
Facility
IP
|
$8.07
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706264
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$7.26 |
| Rate for Payer: Aetna of IA Commercial |
$7.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.26
|
| Rate for Payer: Cash Price |
$6.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.05
|
| Rate for Payer: Medical Associates Commercial |
$6.05
|
| Rate for Payer: Midlands Choice Commercial |
$5.65
|
| Rate for Payer: United Healthcare Commercial |
$7.26
|
|
|
levalbuterol 1.25 mg/0.5 mL neb Sol SDV
|
Facility
IP
|
$9.81
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706226
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Aetna of IA Commercial |
$8.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.83
|
| Rate for Payer: Cash Price |
$7.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.36
|
| Rate for Payer: Medical Associates Commercial |
$7.36
|
| Rate for Payer: Midlands Choice Commercial |
$6.87
|
| Rate for Payer: United Healthcare Commercial |
$8.83
|
|
|
levalbuterol 1.25 mg/0.5 mL neb Sol SDV
|
Facility
OP
|
$9.81
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706226
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$8.83 |
| Rate for Payer: Aetna of IA Commercial |
$8.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.83
|
| Rate for Payer: Aetna of IA Medicare |
$5.59
|
| Rate for Payer: Amerigroup Medicaid |
$4.95
|
| Rate for Payer: Amerigroup Medicare |
$4.95
|
| Rate for Payer: Cash Price |
$7.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.90
|
| Rate for Payer: Medical Associates Commercial |
$7.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.90
|
| Rate for Payer: Midlands Choice Commercial |
$6.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.36
|
| Rate for Payer: United Healthcare Commercial |
$8.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.79
|
|
|
levalbuterol 1.25 mg/3 mL neb Sol SDV
|
Facility
IP
|
$8.82
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$7.94 |
| Rate for Payer: Aetna of IA Commercial |
$7.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.94
|
| Rate for Payer: Cash Price |
$7.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.62
|
| Rate for Payer: Medical Associates Commercial |
$6.62
|
| Rate for Payer: Midlands Choice Commercial |
$6.17
|
| Rate for Payer: United Healthcare Commercial |
$7.94
|
|
|
levalbuterol 1.25 mg/3 mL neb Sol SDV
|
Facility
OP
|
$8.82
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706266
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$7.94 |
| Rate for Payer: Aetna of IA Commercial |
$7.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.94
|
| Rate for Payer: Aetna of IA Medicare |
$5.03
|
| Rate for Payer: Amerigroup Medicaid |
$4.45
|
| Rate for Payer: Amerigroup Medicare |
$4.45
|
| Rate for Payer: Cash Price |
$7.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.41
|
| Rate for Payer: Medical Associates Commercial |
$6.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.41
|
| Rate for Payer: Midlands Choice Commercial |
$6.17
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.62
|
| Rate for Payer: United Healthcare Commercial |
$7.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.20
|
|
|
LEVEL 1
|
Facility
IP
|
$179.00
|
|
|
Service Code
|
CPT 99281 25
|
| Hospital Charge Code |
6922784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
|
|
LEVEL 1
|
Professional
|
$70.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
7982755
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of IA Medicare |
$10.43
|
| Rate for Payer: Amerigroup Medicaid |
$10.78
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.64
|
| Rate for Payer: Medical Associates Commercial |
$19.82
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.43
|
| Rate for Payer: Midlands Choice Commercial |
$49.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.64
|
| Rate for Payer: Wellmark IA HMO |
$18.50
|
| Rate for Payer: Wellmark IA PPO |
$18.50
|
|
|
LEVEL 1
|
Facility
OP
|
$179.00
|
|
|
Service Code
|
CPT 99281 25
|
| Hospital Charge Code |
6922784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$89.46 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Aetna of IA Medicare |
$102.03
|
| Rate for Payer: Amerigroup Medicaid |
$90.34
|
| Rate for Payer: Amerigroup Medicare |
$90.40
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$89.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.46
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$89.50
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$90.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$134.25
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$105.61
|
|
|
LEVEL 2
|
Facility
OP
|
$249.00
|
|
|
Service Code
|
CPT 99282 25
|
| Hospital Charge Code |
6922786
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$124.45 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna of IA Commercial |
$224.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$224.10
|
| Rate for Payer: Aetna of IA Medicare |
$141.93
|
| Rate for Payer: Amerigroup Medicaid |
$125.67
|
| Rate for Payer: Amerigroup Medicare |
$125.74
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$186.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$124.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$124.45
|
| Rate for Payer: Medical Associates Commercial |
$186.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$124.50
|
| Rate for Payer: Midlands Choice Commercial |
$174.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$126.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$186.75
|
| Rate for Payer: United Healthcare Commercial |
$224.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$146.91
|
|
|
LEVEL 2
|
Facility
IP
|
$249.00
|
|
|
Service Code
|
CPT 99282 25
|
| Hospital Charge Code |
6922786
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$174.30 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna of IA Commercial |
$224.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$224.10
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$186.75
|
| Rate for Payer: Medical Associates Commercial |
$186.75
|
| Rate for Payer: Midlands Choice Commercial |
$174.30
|
| Rate for Payer: United Healthcare Commercial |
$224.10
|
|
