|
LIGATION OF HEMORRHOID(S)
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
CPT 46221
|
| Hospital Charge Code |
4864973
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$366.75 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Aetna of IA Medicare |
$464.55
|
| Rate for Payer: Amerigroup Medicaid |
$470.09
|
| Rate for Payer: Amerigroup Medicare |
$370.42
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$366.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$465.53
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$366.75
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$472.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$421.76
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$480.85
|
|
|
Light Chains Quantitative DMCL
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
8037726
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna of IA Commercial |
$117.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.00
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$97.50
|
| Rate for Payer: Medical Associates Commercial |
$97.50
|
| Rate for Payer: Midlands Choice Commercial |
$91.00
|
| Rate for Payer: United Healthcare Commercial |
$117.00
|
|
|
Light Chains Quantitative DMCL
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
8037726
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna of IA Commercial |
$117.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.00
|
| Rate for Payer: Aetna of IA Medicare |
$74.10
|
| Rate for Payer: Amerigroup Medicaid |
$74.98
|
| Rate for Payer: Amerigroup Medicare |
$59.09
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$97.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.26
|
| Rate for Payer: Medical Associates Commercial |
$97.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.50
|
| Rate for Payer: Midlands Choice Commercial |
$91.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$75.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$67.28
|
| Rate for Payer: United Healthcare Commercial |
$117.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.70
|
|
|
linaclotide 145 mcg Cap [VDMC]
|
Facility
|
IP
|
$67.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400672
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.11 |
| Max. Negotiated Rate |
$60.57 |
| Rate for Payer: Aetna of IA Commercial |
$60.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.57
|
| Rate for Payer: Cash Price |
$53.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.48
|
| Rate for Payer: Medical Associates Commercial |
$50.48
|
| Rate for Payer: Midlands Choice Commercial |
$47.11
|
| Rate for Payer: United Healthcare Commercial |
$60.57
|
|
|
linaclotide 145 mcg Cap [VDMC]
|
Facility
|
OP
|
$67.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400672
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.29 |
| Max. Negotiated Rate |
$60.57 |
| Rate for Payer: Aetna of IA Commercial |
$60.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.57
|
| Rate for Payer: Aetna of IA Medicare |
$38.36
|
| Rate for Payer: Amerigroup Medicaid |
$38.82
|
| Rate for Payer: Amerigroup Medicare |
$30.59
|
| Rate for Payer: Cash Price |
$53.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.29
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.44
|
| Rate for Payer: Medical Associates Commercial |
$50.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.29
|
| Rate for Payer: Midlands Choice Commercial |
$47.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$39.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.83
|
| Rate for Payer: United Healthcare Commercial |
$60.57
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.71
|
|
|
linagliptin 5 mg Tab [VDMC]
|
Facility
|
OP
|
$51.23
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400810
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.05 |
| Max. Negotiated Rate |
$46.11 |
| Rate for Payer: Aetna of IA Commercial |
$46.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.11
|
| Rate for Payer: Aetna of IA Medicare |
$29.20
|
| Rate for Payer: Amerigroup Medicaid |
$29.55
|
| Rate for Payer: Amerigroup Medicare |
$23.28
|
| Rate for Payer: Cash Price |
$40.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$29.26
|
| Rate for Payer: Medical Associates Commercial |
$38.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.05
|
| Rate for Payer: Midlands Choice Commercial |
$35.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.51
|
| Rate for Payer: United Healthcare Commercial |
$46.11
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.23
|
|
|
linagliptin 5 mg Tab [VDMC]
|
Facility
|
IP
|
$51.23
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400810
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.86 |
| Max. Negotiated Rate |
$46.11 |
| Rate for Payer: Aetna of IA Commercial |
$46.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.11
|
| Rate for Payer: Cash Price |
$40.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.42
|
| Rate for Payer: Medical Associates Commercial |
$38.42
|
| Rate for Payer: Midlands Choice Commercial |
$35.86
|
| Rate for Payer: United Healthcare Commercial |
$46.11
|
|
|
linezolid 2 mg/mL-D5% 300ml [VDMC]
|
Facility
|
OP
|
$84.92
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
16670233
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.21 |
| Max. Negotiated Rate |
$76.43 |
| Rate for Payer: Aetna of IA Commercial |
$76.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.43
|
| Rate for Payer: Aetna of IA Medicare |
$48.40
|
| Rate for Payer: Amerigroup Medicaid |
$48.98
|
| Rate for Payer: Amerigroup Medicare |
$38.60
|
| Rate for Payer: Cash Price |
$67.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$38.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$48.51
|
| Rate for Payer: Medical Associates Commercial |
$63.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$38.21
|
| Rate for Payer: Midlands Choice Commercial |
$59.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$49.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$43.95
|
| Rate for Payer: United Healthcare Commercial |
$76.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$50.10
|
|
|
linezolid 2 mg/mL-D5% 300ml [VDMC]
|
Facility
|
IP
|
$84.92
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
16670233
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$59.44 |
| Max. Negotiated Rate |
$76.43 |
| Rate for Payer: Aetna of IA Commercial |
$76.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.43
|
| Rate for Payer: Cash Price |
$67.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.69
|
| Rate for Payer: Medical Associates Commercial |
$63.69
|
| Rate for Payer: Midlands Choice Commercial |
$59.44
|
| Rate for Payer: United Healthcare Commercial |
$76.43
|
|
|
linezolid 600 mg Tab [VDMC]
|
Facility
|
IP
|
$7.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400948
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$7.17 |
| Rate for Payer: Aetna of IA Commercial |
$7.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.17
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.97
|
| Rate for Payer: Medical Associates Commercial |
$5.97
|
| Rate for Payer: Midlands Choice Commercial |
$5.57
|
| Rate for Payer: United Healthcare Commercial |
$7.17
|
|
|
linezolid 600 mg Tab [VDMC]
|
Facility
|
OP
|
$7.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400948
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$7.17 |
| Rate for Payer: Aetna of IA Commercial |
$7.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.17
|
| Rate for Payer: Aetna of IA Medicare |
$4.54
|
| Rate for Payer: Amerigroup Medicaid |
$4.59
|
| Rate for Payer: Amerigroup Medicare |
$3.62
|
| Rate for Payer: Cash Price |
$6.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.55
|
| Rate for Payer: Medical Associates Commercial |
$5.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.58
|
| Rate for Payer: Midlands Choice Commercial |
$5.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.12
|
| Rate for Payer: United Healthcare Commercial |
$7.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.70
|
|
|
liothyronine 5 mcg Tab [VDMC]
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10401017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna of IA Commercial |
$2.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.34
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.95
|
| Rate for Payer: Medical Associates Commercial |
$1.95
|
| Rate for Payer: Midlands Choice Commercial |
$1.82
|
| Rate for Payer: United Healthcare Commercial |
$2.34
|
|
|
liothyronine 5 mcg Tab [VDMC]
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10401017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna of IA Commercial |
$2.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.34
|
| Rate for Payer: Aetna of IA Medicare |
$1.48
|
| Rate for Payer: Amerigroup Medicaid |
$1.50
|
| Rate for Payer: Amerigroup Medicare |
$1.18
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.17
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.48
|
| Rate for Payer: Medical Associates Commercial |
$1.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.17
|
| Rate for Payer: Midlands Choice Commercial |
$1.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$2.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.53
|
|
|
LIPASE
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 83690
|
| Hospital Charge Code |
633776
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of IA Commercial |
$64.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.80
|
| Rate for Payer: Aetna of IA Medicare |
$41.04
|
| Rate for Payer: Amerigroup Medicaid |
$41.53
|
| Rate for Payer: Amerigroup Medicare |
$32.72
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$41.13
|
| Rate for Payer: Medical Associates Commercial |
$54.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.40
|
| Rate for Payer: Midlands Choice Commercial |
$50.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$37.26
|
| Rate for Payer: United Healthcare Commercial |
$64.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$42.48
|
|
|
LIPASE
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 83690
|
| Hospital Charge Code |
633776
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of IA Commercial |
$64.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.80
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.00
|
| Rate for Payer: Medical Associates Commercial |
$54.00
|
| Rate for Payer: Midlands Choice Commercial |
$50.40
|
| Rate for Payer: United Healthcare Commercial |
$64.80
|
|
|
lipase-protease-amylase 12000-38000-60000 units Cap [VDMC]
|
Facility
|
IP
|
$15.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10411455
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna of IA Commercial |
$14.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.00
|
| Rate for Payer: Cash Price |
$12.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.67
|
| Rate for Payer: Medical Associates Commercial |
$11.67
|
| Rate for Payer: Midlands Choice Commercial |
$10.89
|
| Rate for Payer: United Healthcare Commercial |
$14.00
|
|
|
lipase-protease-amylase 12000-38000-60000 units Cap [VDMC]
|
Facility
|
OP
|
$15.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10411455
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna of IA Commercial |
$14.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.00
|
| Rate for Payer: Aetna of IA Medicare |
$8.87
|
| Rate for Payer: Amerigroup Medicaid |
$8.97
|
| Rate for Payer: Amerigroup Medicare |
$7.07
|
| Rate for Payer: Cash Price |
$12.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.67
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.88
|
| Rate for Payer: Medical Associates Commercial |
$11.67
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.00
|
| Rate for Payer: Midlands Choice Commercial |
$10.89
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.05
|
| Rate for Payer: United Healthcare Commercial |
$14.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.18
|
|
|
LIPECTOMY CHARGE
|
Professional
|
Both
|
$3,054.00
|
|
|
Service Code
|
CPT 15832
|
| Hospital Charge Code |
8068936
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,394.46 |
| Max. Negotiated Rate |
$2,290.50 |
| Rate for Payer: Cash Price |
$2,443.20
|
| Rate for Payer: Cash Price |
$2,443.20
|
| Rate for Payer: Medical Associates Commercial |
$2,290.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,137.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,290.50
|
| Rate for Payer: United Healthcare Commercial |
$1,394.46
|
|
|
LIPID PROFILE
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
633777
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.05 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Aetna of IA Medicare |
$62.13
|
| Rate for Payer: Amerigroup Medicaid |
$62.87
|
| Rate for Payer: Amerigroup Medicare |
$49.54
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.26
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.05
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.41
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.31
|
|
|
LIPID PROFILE
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 80061
|
| Hospital Charge Code |
633777
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
|
|
Lipoprotein A DMCL
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 83695
|
| Hospital Charge Code |
8632496
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna of IA Commercial |
$126.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.00
|
| Rate for Payer: Medical Associates Commercial |
$105.00
|
| Rate for Payer: Midlands Choice Commercial |
$98.00
|
| Rate for Payer: United Healthcare Commercial |
$126.00
|
|
|
Lipoprotein A DMCL
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 83695
|
| Hospital Charge Code |
8632496
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna of IA Commercial |
$126.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.00
|
| Rate for Payer: Aetna of IA Medicare |
$79.80
|
| Rate for Payer: Amerigroup Medicaid |
$80.75
|
| Rate for Payer: Amerigroup Medicare |
$63.63
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$63.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$79.97
|
| Rate for Payer: Medical Associates Commercial |
$105.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$63.00
|
| Rate for Payer: Midlands Choice Commercial |
$98.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$81.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$72.45
|
| Rate for Payer: United Healthcare Commercial |
$126.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.60
|
|
|
liraglutide 18 mg/3 mL Sol [VDMC]
|
Facility
|
IP
|
$1,019.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10401086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$713.90 |
| Max. Negotiated Rate |
$917.87 |
| Rate for Payer: Aetna of IA Commercial |
$917.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$917.87
|
| Rate for Payer: Cash Price |
$815.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$764.89
|
| Rate for Payer: Medical Associates Commercial |
$764.89
|
| Rate for Payer: Midlands Choice Commercial |
$713.90
|
| Rate for Payer: United Healthcare Commercial |
$917.87
|
|
|
liraglutide 18 mg/3 mL Sol [VDMC]
|
Facility
|
OP
|
$1,019.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10401086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$458.94 |
| Max. Negotiated Rate |
$917.87 |
| Rate for Payer: Aetna of IA Commercial |
$917.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$917.87
|
| Rate for Payer: Aetna of IA Medicare |
$581.32
|
| Rate for Payer: Amerigroup Medicaid |
$588.26
|
| Rate for Payer: Amerigroup Medicare |
$463.53
|
| Rate for Payer: Cash Price |
$815.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$764.89
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$458.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$582.54
|
| Rate for Payer: Medical Associates Commercial |
$764.89
|
| Rate for Payer: Medical Associates Managed Medicare |
$458.94
|
| Rate for Payer: Midlands Choice Commercial |
$713.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$591.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$527.78
|
| Rate for Payer: United Healthcare Commercial |
$917.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$601.72
|
|
|
lisinopril 20 mg Tab [VDMC]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10429571
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of IA Commercial |
$1.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.06
|
| Rate for Payer: Aetna of IA Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicaid |
$0.68
|
| Rate for Payer: Amerigroup Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.53
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.67
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.53
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.70
|
|
