|
LENS TORIC 14.0 SN6AT9+14.0D
|
Facility
|
OP
|
$584.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8936672
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$291.88 |
| Max. Negotiated Rate |
$525.60 |
| Rate for Payer: Aetna of IA Commercial |
$525.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$525.60
|
| Rate for Payer: Aetna of IA Medicare |
$332.88
|
| Rate for Payer: Amerigroup Medicaid |
$294.74
|
| Rate for Payer: Amerigroup Medicare |
$294.92
|
| Rate for Payer: Cash Price |
$467.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$438.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$292.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$291.88
|
| Rate for Payer: Medical Associates Commercial |
$438.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$292.00
|
| Rate for Payer: Midlands Choice Commercial |
$408.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$296.38
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$296.20
|
| Rate for Payer: Oscar Health of IA Commercial |
$438.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$438.00
|
| Rate for Payer: United Healthcare Commercial |
$525.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$344.56
|
|
|
LENS TORIC 14.0 SN6AT9+14.0D
|
Facility
|
IP
|
$584.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8936672
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$408.80 |
| Max. Negotiated Rate |
$525.60 |
| Rate for Payer: Aetna of IA Commercial |
$525.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$525.60
|
| Rate for Payer: Cash Price |
$467.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$438.00
|
| Rate for Payer: Medical Associates Commercial |
$438.00
|
| Rate for Payer: Midlands Choice Commercial |
$408.80
|
| Rate for Payer: United Healthcare Commercial |
$525.60
|
|
|
LENS TORIC 18.5 SN6AT418.5D
|
Facility
|
IP
|
$891.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8931527
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$623.70 |
| Max. Negotiated Rate |
$801.90 |
| Rate for Payer: Aetna of IA Commercial |
$801.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$801.90
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$668.25
|
| Rate for Payer: Medical Associates Commercial |
$668.25
|
| Rate for Payer: Midlands Choice Commercial |
$623.70
|
| Rate for Payer: United Healthcare Commercial |
$801.90
|
|
|
LENS TORIC 18.5 SN6AT418.5D
|
Facility
|
OP
|
$891.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8931527
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$445.32 |
| Max. Negotiated Rate |
$801.90 |
| Rate for Payer: Aetna of IA Commercial |
$801.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$801.90
|
| Rate for Payer: Aetna of IA Medicare |
$507.87
|
| Rate for Payer: Amerigroup Medicaid |
$449.69
|
| Rate for Payer: Amerigroup Medicare |
$449.96
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$668.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$445.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$445.32
|
| Rate for Payer: Medical Associates Commercial |
$668.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$445.50
|
| Rate for Payer: Midlands Choice Commercial |
$623.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$452.18
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$451.92
|
| Rate for Payer: Oscar Health of IA Commercial |
$668.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$668.25
|
| Rate for Payer: United Healthcare Commercial |
$801.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$525.69
|
|
|
LENS TORIC 21.0 SN6AT421.0D
|
Facility
|
OP
|
$584.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8936670
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$291.88 |
| Max. Negotiated Rate |
$525.60 |
| Rate for Payer: Aetna of IA Commercial |
$525.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$525.60
|
| Rate for Payer: Aetna of IA Medicare |
$332.88
|
| Rate for Payer: Amerigroup Medicaid |
$294.74
|
| Rate for Payer: Amerigroup Medicare |
$294.92
|
| Rate for Payer: Cash Price |
$467.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$438.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$292.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$291.88
|
| Rate for Payer: Medical Associates Commercial |
$438.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$292.00
|
| Rate for Payer: Midlands Choice Commercial |
$408.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$296.38
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$296.20
|
| Rate for Payer: Oscar Health of IA Commercial |
$438.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$438.00
|
| Rate for Payer: United Healthcare Commercial |
$525.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$344.56
|
|
|
LENS TORIC 21.0 SN6AT421.0D
|
Facility
|
IP
|
$584.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8936670
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$408.80 |
| Max. Negotiated Rate |
$525.60 |
| Rate for Payer: Aetna of IA Commercial |
$525.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$525.60
|
| Rate for Payer: Cash Price |
$467.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$438.00
|
| Rate for Payer: Medical Associates Commercial |
$438.00
|
| Rate for Payer: Midlands Choice Commercial |
$408.80
|
| Rate for Payer: United Healthcare Commercial |
$525.60
|
|
|
LENS TORIC ASTIGMATISM-OR TO PROVIDE REF
|
Facility
|
OP
|
$375.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8046975
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$187.42 |
| 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 |
$189.26
|
| Rate for Payer: Amerigroup Medicare |
$189.38
|
| 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 |
$187.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$187.42
|
| Rate for Payer: Medical Associates Commercial |
$281.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$187.50
|
| Rate for Payer: Midlands Choice Commercial |
$262.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$190.31
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$190.20
|
| Rate for Payer: Oscar Health of IA Commercial |
$281.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$281.25
|
| Rate for Payer: United Healthcare Commercial |
$337.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$221.25
|
|
|
LENS TORIC ASTIGMATISM-OR TO PROVIDE REF
|
Facility
|
IP
|
$375.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8046975
|
|
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
|
|
|
letrozole 2.5 mg Tab [VDMC]
|
Facility
|
OP
|
$85.85
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11224581
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.91 |
| Max. Negotiated Rate |
$77.26 |
| Rate for Payer: Aetna of IA Commercial |
$77.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$77.26
|
| Rate for Payer: Aetna of IA Medicare |
$48.93
|
| Rate for Payer: Amerigroup Medicaid |
$43.33
|
| Rate for Payer: Amerigroup Medicare |
$43.35
|
| Rate for Payer: Cash Price |
$68.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$64.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$42.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$42.91
|
| Rate for Payer: Medical Associates Commercial |
$64.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$42.92
|
| Rate for Payer: Midlands Choice Commercial |
$60.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$43.57
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$43.54
|
| Rate for Payer: Oscar Health of IA Commercial |
$64.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$64.39
|
| Rate for Payer: United Healthcare Commercial |
$77.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$50.65
|
|
|
letrozole 2.5 mg Tab [VDMC]
|
Facility
|
IP
|
$85.85
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11224581
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.10 |
| Max. Negotiated Rate |
$77.26 |
| Rate for Payer: Aetna of IA Commercial |
$77.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$77.26
|
| Rate for Payer: Cash Price |
$68.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$64.39
|
| Rate for Payer: Medical Associates Commercial |
$64.39
|
| Rate for Payer: Midlands Choice Commercial |
$60.10
|
| Rate for Payer: United Healthcare Commercial |
$77.26
|
|
|
leucovorin 200 mg SDV Pow [VDMC]
|
Facility
|
IP
|
$86.92
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
22207322
|
|
Hospital Revenue Code
|
259
|
| 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 200 mg SDV Pow [VDMC]
|
Facility
|
OP
|
$86.92
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
22207322
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$44.09
|
| Rate for Payer: Oscar Health of IA Commercial |
$65.19
|
| 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 350 mg Pow SDV [VDMC]
|
Facility
|
OP
|
$95.68
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
19322806
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$48.53
|
| Rate for Payer: Oscar Health of IA Commercial |
$71.76
|
| 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 [VDMC]
|
Facility
|
IP
|
$95.68
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
19322806
|
|
Hospital Revenue Code
|
259
|
| 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[VDMC]
|
Facility
|
IP
|
$11,935.30
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
12612356
|
|
Hospital Revenue Code
|
259
|
| 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 22.5 mg/3 months Pow[VDMC]
|
Facility
|
OP
|
$11,935.30
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
12612356
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$6,053.58
|
| Rate for Payer: Oscar Health of IA Commercial |
$8,951.48
|
| 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 30 mg/4 months Pow [VDMC]
|
Facility
|
IP
|
$10,856.72
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
14489192
|
|
Hospital Revenue Code
|
259
|
| 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 30 mg/4 months Pow [VDMC]
|
Facility
|
OP
|
$10,856.72
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
14489192
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$5,506.53
|
| Rate for Payer: Oscar Health of IA Commercial |
$8,142.54
|
| 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 3.75 mg/month Pow[VDMC]
|
Facility
|
OP
|
$3,410.62
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13415053
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$1,729.87
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,557.96
|
| 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[VDMC]
|
Facility
|
IP
|
$3,410.62
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13415053
|
|
Hospital Revenue Code
|
259
|
| 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[VDMC]
|
Facility
|
OP
|
$14,914.52
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
12806940
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$7,564.64
|
| Rate for Payer: Oscar Health of IA Commercial |
$11,185.89
|
| 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 45 mg/6 months Pow[VDMC]
|
Facility
|
IP
|
$14,914.52
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
12806940
|
|
Hospital Revenue Code
|
259
|
| 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 7.5 mg/month IM Inj, ER [VDMC]
|
Facility
|
OP
|
$3,528.86
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
10399232
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$1,789.84
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,646.64
|
| 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 [VDMC]
|
Facility
|
IP
|
$3,528.86
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
10399232
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$8.07
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399370
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$4.09
|
| Rate for Payer: Oscar Health of IA Commercial |
$6.05
|
| 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
|
|
