|
LENS ALCON 9.5
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
8896435
|
|
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 ALCON 9.5
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
8896435
|
|
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-PANOPTIX
|
Facility
|
OP
|
$845.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
8818765
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$380.25 |
| Max. Negotiated Rate |
$760.50 |
| Rate for Payer: Aetna of IA Commercial |
$760.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$760.50
|
| Rate for Payer: Aetna of IA Medicare |
$481.65
|
| Rate for Payer: Amerigroup Medicaid |
$487.40
|
| Rate for Payer: Amerigroup Medicare |
$384.05
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$633.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$380.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$482.66
|
| Rate for Payer: Medical Associates Commercial |
$633.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$380.25
|
| Rate for Payer: Midlands Choice Commercial |
$591.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$489.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$437.29
|
| Rate for Payer: United Healthcare Commercial |
$760.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$498.55
|
|
|
LENS-PANOPTIX
|
Facility
|
IP
|
$845.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
8818765
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$591.50 |
| Max. Negotiated Rate |
$760.50 |
| Rate for Payer: Aetna of IA Commercial |
$760.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$760.50
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$633.75
|
| Rate for Payer: Medical Associates Commercial |
$633.75
|
| Rate for Payer: Midlands Choice Commercial |
$591.50
|
| Rate for Payer: United Healthcare Commercial |
$760.50
|
|
|
LENS POSTERIOR 5.0
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
8047351
|
|
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 POSTERIOR 5.0
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
8047351
|
|
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 RESTORE
|
Facility
|
OP
|
$845.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
8046977
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$380.25 |
| Max. Negotiated Rate |
$760.50 |
| Rate for Payer: Aetna of IA Commercial |
$760.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$760.50
|
| Rate for Payer: Aetna of IA Medicare |
$481.65
|
| Rate for Payer: Amerigroup Medicaid |
$487.40
|
| Rate for Payer: Amerigroup Medicare |
$384.05
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$633.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$380.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$482.66
|
| Rate for Payer: Medical Associates Commercial |
$633.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$380.25
|
| Rate for Payer: Midlands Choice Commercial |
$591.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$489.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$437.29
|
| Rate for Payer: United Healthcare Commercial |
$760.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$498.55
|
|
|
LENS RESTORE
|
Facility
|
IP
|
$845.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
8046977
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$591.50 |
| Max. Negotiated Rate |
$760.50 |
| Rate for Payer: Aetna of IA Commercial |
$760.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$760.50
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$633.75
|
| Rate for Payer: Medical Associates Commercial |
$633.75
|
| Rate for Payer: Midlands Choice Commercial |
$591.50
|
| Rate for Payer: United Healthcare Commercial |
$760.50
|
|
|
LENS TORIC ASTIGMATISM-OR TO PROVIDE REF
|
Facility
|
OP
|
$375.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
8046975
|
|
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 TORIC ASTIGMATISM-OR TO PROVIDE REF
|
Facility
|
IP
|
$375.00
|
|
|
Service Code
|
HCPCS 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
|
|
|
leuprolide 11.25 mg/3 months Pow[VDMC]
|
Facility
|
OP
|
$10,031.92
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
29117625
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,514.36 |
| Max. Negotiated Rate |
$9,028.73 |
| Rate for Payer: Aetna of IA Commercial |
$9,028.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9,028.73
|
| Rate for Payer: Aetna of IA Medicare |
$5,718.19
|
| Rate for Payer: Amerigroup Medicaid |
$5,786.41
|
| Rate for Payer: Amerigroup Medicare |
$4,559.51
|
| Rate for Payer: Cash Price |
$8,025.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7,523.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,514.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5,730.23
|
| Rate for Payer: Medical Associates Commercial |
$7,523.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,514.36
|
| Rate for Payer: Midlands Choice Commercial |
$7,022.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,814.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$5,191.52
|
| Rate for Payer: United Healthcare Commercial |
$9,028.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$5,918.83
|
|
|
leuprolide 11.25 mg/3 months Pow[VDMC]
|
Facility
|
IP
|
$10,031.92
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
29117625
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7,022.34 |
| Max. Negotiated Rate |
$9,028.73 |
| Rate for Payer: Aetna of IA Commercial |
$9,028.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9,028.73
|
| Rate for Payer: Cash Price |
$8,025.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7,523.94
|
| Rate for Payer: Medical Associates Commercial |
$7,523.94
|
| Rate for Payer: Midlands Choice Commercial |
$7,022.34
|
| Rate for Payer: United Healthcare Commercial |
$9,028.73
|
|
|
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 |
$5,370.89 |
| 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 |
$6,884.28
|
| Rate for Payer: Amerigroup Medicare |
$5,424.59
|
| 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 |
$5,370.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,817.44
|
| Rate for Payer: Medical Associates Commercial |
$8,951.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$5,370.89
|
| Rate for Payer: Midlands Choice Commercial |
$8,354.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,917.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,176.52
|
| 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[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 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 |
$4,885.52 |
| 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 |
$6,262.16
|
| Rate for Payer: Amerigroup Medicare |
$4,934.38
|
| 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 |
$4,885.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,201.36
|
| Rate for Payer: Medical Associates Commercial |
$8,142.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,885.52
|
| Rate for Payer: Midlands Choice Commercial |
$7,599.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,292.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$5,618.35
|
| 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 [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 3.75 mg/month Pow[VDMC]
|
Facility
|
IP
|
$3,576.16
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13415053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,503.31 |
| Max. Negotiated Rate |
$3,218.54 |
| Rate for Payer: Aetna of IA Commercial |
$3,218.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,218.54
|
| Rate for Payer: Cash Price |
$2,860.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,682.12
|
| Rate for Payer: Medical Associates Commercial |
$2,682.12
|
| Rate for Payer: Midlands Choice Commercial |
$2,503.31
|
| Rate for Payer: United Healthcare Commercial |
$3,218.54
|
|
|
leuprolide 3.75 mg/month Pow[VDMC]
|
Facility
|
OP
|
$3,576.16
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13415053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,609.27 |
| Max. Negotiated Rate |
$3,218.54 |
| Rate for Payer: Aetna of IA Commercial |
$3,218.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,218.54
|
| Rate for Payer: Aetna of IA Medicare |
$2,038.41
|
| Rate for Payer: Amerigroup Medicaid |
$2,062.73
|
| Rate for Payer: Amerigroup Medicare |
$1,625.36
|
| Rate for Payer: Cash Price |
$2,860.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,682.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,609.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,042.70
|
| Rate for Payer: Medical Associates Commercial |
$2,682.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,609.27
|
| Rate for Payer: Midlands Choice Commercial |
$2,503.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,072.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,850.66
|
| Rate for Payer: United Healthcare Commercial |
$3,218.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,109.93
|
|
|
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
|
|
|
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 |
$1,587.99 |
| 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 |
$2,035.45
|
| Rate for Payer: Amerigroup Medicare |
$1,603.87
|
| 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 |
$1,587.99
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,015.68
|
| Rate for Payer: Medical Associates Commercial |
$2,646.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,587.99
|
| Rate for Payer: Midlands Choice Commercial |
$2,470.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,045.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,826.19
|
| Rate for Payer: United Healthcare Commercial |
$3,175.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,082.03
|
|
|
levalbuterol 0.63 mg/3 mL neb Sol SDV [VDMC]
|
Facility
|
OP
|
$9.26
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399370
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: Aetna of IA Commercial |
$8.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.34
|
| Rate for Payer: Aetna of IA Medicare |
$5.28
|
| Rate for Payer: Amerigroup Medicaid |
$5.34
|
| Rate for Payer: Amerigroup Medicare |
$4.21
|
| Rate for Payer: Cash Price |
$7.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.17
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.29
|
| Rate for Payer: Medical Associates Commercial |
$6.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.17
|
| Rate for Payer: Midlands Choice Commercial |
$6.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.79
|
| Rate for Payer: United Healthcare Commercial |
$8.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.47
|
|
|
levalbuterol 0.63 mg/3 mL neb Sol SDV [VDMC]
|
Facility
|
IP
|
$9.26
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399370
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: Aetna of IA Commercial |
$8.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.34
|
| Rate for Payer: Cash Price |
$7.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.95
|
| Rate for Payer: Medical Associates Commercial |
$6.95
|
| Rate for Payer: Midlands Choice Commercial |
$6.48
|
| Rate for Payer: United Healthcare Commercial |
$8.34
|
|
|
levalbuterol 1.25 mg/3 mL neb Sol SDV [VDMC]
|
Facility
|
OP
|
$8.82
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399441
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.97 |
| 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 |
$5.09
|
| Rate for Payer: Amerigroup Medicare |
$4.01
|
| 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 |
$3.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.04
|
| Rate for Payer: Medical Associates Commercial |
$6.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.97
|
| Rate for Payer: Midlands Choice Commercial |
$6.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.57
|
| Rate for Payer: United Healthcare Commercial |
$7.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.21
|
|
|
levalbuterol 1.25 mg/3 mL neb Sol SDV [VDMC]
|
Facility
|
IP
|
$8.82
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399441
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.18 |
| 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 |
$6.18
|
| Rate for Payer: United Healthcare Commercial |
$7.94
|
|
|
Level 1
|
Facility
|
IP
|
$890.00
|
|
| Hospital Charge Code |
1378485
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$623.00 |
| Max. Negotiated Rate |
$801.00 |
| Rate for Payer: Aetna of IA Commercial |
$801.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$801.00
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$667.50
|
| Rate for Payer: Medical Associates Commercial |
$667.50
|
| Rate for Payer: Midlands Choice Commercial |
$623.00
|
| Rate for Payer: United Healthcare Commercial |
$801.00
|
|
