|
magnesium sulfate 2 g/50 mL-sterile water 50ml [VDMC]
|
Facility
|
OP
|
$96.30
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
27167226
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$43.34 |
| Max. Negotiated Rate |
$86.67 |
| Rate for Payer: Aetna of IA Commercial |
$86.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.67
|
| Rate for Payer: Aetna of IA Medicare |
$54.89
|
| Rate for Payer: Amerigroup Medicaid |
$55.55
|
| Rate for Payer: Amerigroup Medicare |
$43.77
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$43.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.01
|
| Rate for Payer: Medical Associates Commercial |
$72.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$43.34
|
| Rate for Payer: Midlands Choice Commercial |
$67.41
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$55.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$49.84
|
| Rate for Payer: United Healthcare Commercial |
$86.67
|
| Rate for Payer: United Healthcare Managed Medicare |
$56.82
|
|
|
magnesium sulfate 2 g/50 mL-sterile water 50ml [VDMC]
|
Facility
|
IP
|
$96.30
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
27167226
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.41 |
| Max. Negotiated Rate |
$86.67 |
| Rate for Payer: Aetna of IA Commercial |
$86.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.67
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.22
|
| Rate for Payer: Medical Associates Commercial |
$72.22
|
| Rate for Payer: Midlands Choice Commercial |
$67.41
|
| Rate for Payer: United Healthcare Commercial |
$86.67
|
|
|
magnesium sulfate 40 mg/mL 1000ml bag [VDMC]
|
Facility
|
IP
|
$83.80
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
10402201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$58.66 |
| Max. Negotiated Rate |
$75.42 |
| Rate for Payer: Aetna of IA Commercial |
$75.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$75.42
|
| Rate for Payer: Cash Price |
$67.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$62.85
|
| Rate for Payer: Medical Associates Commercial |
$62.85
|
| Rate for Payer: Midlands Choice Commercial |
$58.66
|
| Rate for Payer: United Healthcare Commercial |
$75.42
|
|
|
magnesium sulfate 40 mg/mL 1000ml bag [VDMC]
|
Facility
|
OP
|
$83.80
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
10402201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$37.71 |
| Max. Negotiated Rate |
$75.42 |
| Rate for Payer: Aetna of IA Commercial |
$75.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$75.42
|
| Rate for Payer: Aetna of IA Medicare |
$47.77
|
| Rate for Payer: Amerigroup Medicaid |
$48.34
|
| Rate for Payer: Amerigroup Medicare |
$38.09
|
| Rate for Payer: Cash Price |
$67.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$62.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$37.71
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$47.87
|
| Rate for Payer: Medical Associates Commercial |
$62.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$37.71
|
| Rate for Payer: Midlands Choice Commercial |
$58.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$48.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$43.37
|
| Rate for Payer: United Healthcare Commercial |
$75.42
|
| Rate for Payer: United Healthcare Managed Medicare |
$49.44
|
|
|
magnesium sulfate 50% 5gm/10ml SDV [VDMC]
|
Facility
|
OP
|
$29.09
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
22490376
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.09 |
| Max. Negotiated Rate |
$26.18 |
| Rate for Payer: Aetna of IA Commercial |
$26.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.18
|
| Rate for Payer: Aetna of IA Medicare |
$16.58
|
| Rate for Payer: Amerigroup Medicaid |
$16.78
|
| Rate for Payer: Amerigroup Medicare |
$13.22
|
| Rate for Payer: Cash Price |
$23.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.82
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.09
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.62
|
| Rate for Payer: Medical Associates Commercial |
$21.82
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.09
|
| Rate for Payer: Midlands Choice Commercial |
$20.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.05
|
| Rate for Payer: United Healthcare Commercial |
$26.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.16
|
|
|
magnesium sulfate 50% 5gm/10ml SDV [VDMC]
|
Facility
|
IP
|
$29.09
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
22490376
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.36 |
| Max. Negotiated Rate |
$26.18 |
| Rate for Payer: Aetna of IA Commercial |
$26.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.18
|
| Rate for Payer: Cash Price |
$23.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.82
|
| Rate for Payer: Medical Associates Commercial |
$21.82
|
| Rate for Payer: Midlands Choice Commercial |
$20.36
|
| Rate for Payer: United Healthcare Commercial |
$26.18
|
|
|
magnesium sulfate 50% Inj Sol 2 mL SDV [VDMC]
|
Facility
|
OP
|
$24.20
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
10435773
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$21.78 |
| Rate for Payer: Aetna of IA Commercial |
$21.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.78
|
| Rate for Payer: Aetna of IA Medicare |
$13.79
|
| Rate for Payer: Amerigroup Medicaid |
$13.96
|
| Rate for Payer: Amerigroup Medicare |
$11.00
|
| Rate for Payer: Cash Price |
$19.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.82
|
| Rate for Payer: Medical Associates Commercial |
$18.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.89
|
| Rate for Payer: Midlands Choice Commercial |
$16.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.52
|
| Rate for Payer: United Healthcare Commercial |
$21.78
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.28
|
|
|
magnesium sulfate 50% Inj Sol 2 mL SDV [VDMC]
|
Facility
|
IP
|
$24.20
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
10435773
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.94 |
| Max. Negotiated Rate |
$21.78 |
| Rate for Payer: Aetna of IA Commercial |
$21.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.78
|
| Rate for Payer: Cash Price |
$19.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.15
|
| Rate for Payer: Medical Associates Commercial |
$18.15
|
| Rate for Payer: Midlands Choice Commercial |
$16.94
|
| Rate for Payer: United Healthcare Commercial |
$21.78
|
|
|
MALLEOLUS IMPLANT 4.5MM X 65MM
|
Facility
|
IP
|
$4,095.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8924289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,866.50 |
| Max. Negotiated Rate |
$3,685.50 |
| Rate for Payer: Aetna of IA Commercial |
$3,685.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,685.50
|
| Rate for Payer: Cash Price |
$3,276.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,071.25
|
| Rate for Payer: Medical Associates Commercial |
$3,071.25
|
| Rate for Payer: Midlands Choice Commercial |
$2,866.50
|
| Rate for Payer: United Healthcare Commercial |
$3,685.50
|
|
|
MALLEOLUS IMPLANT 4.5MM X 65MM
|
Facility
|
OP
|
$4,095.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8924289
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,842.75 |
| Max. Negotiated Rate |
$3,685.50 |
| Rate for Payer: Aetna of IA Commercial |
$3,685.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,685.50
|
| Rate for Payer: Aetna of IA Medicare |
$2,334.15
|
| Rate for Payer: Amerigroup Medicaid |
$2,362.00
|
| Rate for Payer: Amerigroup Medicare |
$1,861.18
|
| Rate for Payer: Cash Price |
$3,276.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,071.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,842.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,339.06
|
| Rate for Payer: Medical Associates Commercial |
$3,071.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,842.75
|
| Rate for Payer: Midlands Choice Commercial |
$2,866.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,373.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,119.16
|
| Rate for Payer: United Healthcare Commercial |
$3,685.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,416.05
|
|
|
mannitol 20% IV Sol 500 ml[VDMC]
|
Facility
|
IP
|
$70.56
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
13192394
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.39 |
| Max. Negotiated Rate |
$63.50 |
| Rate for Payer: Aetna of IA Commercial |
$63.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.50
|
| Rate for Payer: Cash Price |
$56.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.92
|
| Rate for Payer: Medical Associates Commercial |
$52.92
|
| Rate for Payer: Midlands Choice Commercial |
$49.39
|
| Rate for Payer: United Healthcare Commercial |
$63.50
|
|
|
mannitol 20% IV Sol 500 ml[VDMC]
|
Facility
|
OP
|
$70.56
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
13192394
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.75 |
| Max. Negotiated Rate |
$63.50 |
| Rate for Payer: Aetna of IA Commercial |
$63.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.50
|
| Rate for Payer: Aetna of IA Medicare |
$40.22
|
| Rate for Payer: Amerigroup Medicaid |
$40.70
|
| Rate for Payer: Amerigroup Medicare |
$32.07
|
| Rate for Payer: Cash Price |
$56.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40.30
|
| Rate for Payer: Medical Associates Commercial |
$52.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.75
|
| Rate for Payer: Midlands Choice Commercial |
$49.39
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$40.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.51
|
| Rate for Payer: United Healthcare Commercial |
$63.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$41.63
|
|
|
MANUAL THERAPY PER 15 MINUTES
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 97140 GP
|
| Hospital Charge Code |
1373910
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$49.95 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Aetna of IA Medicare |
$63.27
|
| Rate for Payer: Amerigroup Medicaid |
$64.02
|
| Rate for Payer: Amerigroup Medicare |
$50.45
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$63.40
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.95
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$64.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.44
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.49
|
|
|
MANUAL THERAPY PER 15 MINUTES
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
750909
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$49.95 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Aetna of IA Medicare |
$63.27
|
| Rate for Payer: Amerigroup Medicaid |
$64.02
|
| Rate for Payer: Amerigroup Medicare |
$50.45
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$63.40
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.95
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$64.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.44
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.49
|
|
|
MANUAL THERAPY PER 15 MINUTES
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 97140 GP
|
| Hospital Charge Code |
1373910
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
|
|
MANUAL THERAPY PER 15 MINUTES
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
750909
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
|
|
MAXIMUM BREATHING CAPACITY
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
CPT 94200
|
| Hospital Charge Code |
5338937
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna of IA Commercial |
$234.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$234.00
|
| Rate for Payer: Aetna of IA Medicare |
$148.20
|
| Rate for Payer: Amerigroup Medicaid |
$149.97
|
| Rate for Payer: Amerigroup Medicare |
$118.17
|
| Rate for Payer: Cash Price |
$208.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$195.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$117.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$148.51
|
| Rate for Payer: Medical Associates Commercial |
$195.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$117.00
|
| Rate for Payer: Midlands Choice Commercial |
$182.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$150.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$134.55
|
| Rate for Payer: United Healthcare Commercial |
$234.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$153.40
|
|
|
MAXIMUM BREATHING CAPACITY
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT 94200
|
| Hospital Charge Code |
5338937
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna of IA Commercial |
$234.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$234.00
|
| Rate for Payer: Cash Price |
$208.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$195.00
|
| Rate for Payer: Medical Associates Commercial |
$195.00
|
| Rate for Payer: Midlands Choice Commercial |
$182.00
|
| Rate for Payer: United Healthcare Commercial |
$234.00
|
|
|
MCL Referred Isolate DMCL
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
8037732
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$26.55 |
| Max. Negotiated Rate |
$53.10 |
| Rate for Payer: Aetna of IA Commercial |
$53.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$53.10
|
| Rate for Payer: Aetna of IA Medicare |
$33.63
|
| Rate for Payer: Amerigroup Medicaid |
$34.03
|
| Rate for Payer: Amerigroup Medicare |
$26.82
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$44.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.70
|
| Rate for Payer: Medical Associates Commercial |
$44.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.55
|
| Rate for Payer: Midlands Choice Commercial |
$41.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$34.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.53
|
| Rate for Payer: United Healthcare Commercial |
$53.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.81
|
|
|
MCL Referred Isolate DMCL
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
8037732
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$53.10 |
| Rate for Payer: Aetna of IA Commercial |
$53.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$53.10
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$44.25
|
| Rate for Payer: Medical Associates Commercial |
$44.25
|
| Rate for Payer: Midlands Choice Commercial |
$41.30
|
| Rate for Payer: United Healthcare Commercial |
$53.10
|
|
|
measles/mumps/rubella/varicella virus vaccine SDV - Pow UD[VDMC]
|
Facility
|
IP
|
$508.42
|
|
|
Service Code
|
HCPCS 90710
|
| Hospital Charge Code |
12455541
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$355.90 |
| Max. Negotiated Rate |
$457.58 |
| Rate for Payer: Aetna of IA Commercial |
$457.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$457.58
|
| Rate for Payer: Cash Price |
$406.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$381.32
|
| Rate for Payer: Medical Associates Commercial |
$381.32
|
| Rate for Payer: Midlands Choice Commercial |
$355.90
|
| Rate for Payer: United Healthcare Commercial |
$457.58
|
|
|
measles/mumps/rubella/varicella virus vaccine SDV - Pow UD[VDMC]
|
Facility
|
OP
|
$508.42
|
|
|
Service Code
|
HCPCS 90710
|
| Hospital Charge Code |
12455541
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$228.79 |
| Max. Negotiated Rate |
$457.58 |
| Rate for Payer: Aetna of IA Commercial |
$457.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$457.58
|
| Rate for Payer: Aetna of IA Medicare |
$289.80
|
| Rate for Payer: Amerigroup Medicaid |
$293.26
|
| Rate for Payer: Amerigroup Medicare |
$231.08
|
| Rate for Payer: Cash Price |
$406.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$381.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$228.79
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$290.41
|
| Rate for Payer: Medical Associates Commercial |
$381.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$228.79
|
| Rate for Payer: Midlands Choice Commercial |
$355.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$294.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$263.11
|
| Rate for Payer: United Healthcare Commercial |
$457.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$299.97
|
|
|
mEAsles/mumps/rubella virus vaccine SubQ Inj [VDMC]
|
Facility
|
IP
|
$195.95
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
10402343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$137.17 |
| Max. Negotiated Rate |
$176.36 |
| Rate for Payer: Aetna of IA Commercial |
$176.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$176.36
|
| Rate for Payer: Cash Price |
$156.76
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$146.97
|
| Rate for Payer: Medical Associates Commercial |
$146.97
|
| Rate for Payer: Midlands Choice Commercial |
$137.17
|
| Rate for Payer: United Healthcare Commercial |
$176.36
|
|
|
mEAsles/mumps/rubella virus vaccine SubQ Inj [VDMC]
|
Facility
|
OP
|
$195.95
|
|
|
Service Code
|
HCPCS 90707
|
| Hospital Charge Code |
10402343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$88.18 |
| Max. Negotiated Rate |
$176.36 |
| Rate for Payer: Aetna of IA Commercial |
$176.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$176.36
|
| Rate for Payer: Aetna of IA Medicare |
$111.69
|
| Rate for Payer: Amerigroup Medicaid |
$113.03
|
| Rate for Payer: Amerigroup Medicare |
$89.06
|
| Rate for Payer: Cash Price |
$156.76
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$146.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$88.18
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$111.93
|
| Rate for Payer: Medical Associates Commercial |
$146.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$88.18
|
| Rate for Payer: Midlands Choice Commercial |
$137.17
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$113.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$101.41
|
| Rate for Payer: United Healthcare Commercial |
$176.36
|
| Rate for Payer: United Healthcare Managed Medicare |
$115.61
|
|
|
meclizine 25 mg Tab [VDMC]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10402412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna of IA Commercial |
$2.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.15
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.79
|
| Rate for Payer: Medical Associates Commercial |
$1.79
|
| Rate for Payer: Midlands Choice Commercial |
$1.67
|
| Rate for Payer: United Healthcare Commercial |
$2.15
|
|
