|
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
|
|
|
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 |
$5,370.88 |
| 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 |
$5,370.88
|
| 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 |
$5,370.88
|
| 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
|
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
|
|
|
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
|
|
|
Level 1
|
Facility
|
OP
|
$890.00
|
|
| Hospital Charge Code |
1378485
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$400.50 |
| 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: Aetna of IA Medicare |
$507.30
|
| Rate for Payer: Amerigroup Medicaid |
$513.35
|
| Rate for Payer: Amerigroup Medicare |
$404.50
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$667.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$400.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$508.37
|
| Rate for Payer: Medical Associates Commercial |
$667.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$400.50
|
| Rate for Payer: Midlands Choice Commercial |
$623.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$515.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$460.58
|
| Rate for Payer: United Healthcare Commercial |
$801.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$525.10
|
|
|
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
|
|
|
LEVEL 1
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
CPT 99281
|
| Hospital Charge Code |
7982755
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$52.50 |
| Rate for Payer: Amerigroup Medicaid |
$10.31
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.21
|
| Rate for Payer: Medical Associates Commercial |
$52.50
|
| Rate for Payer: Midlands Choice Commercial |
$49.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$52.50
|
| Rate for Payer: United Healthcare Commercial |
$24.94
|
| Rate for Payer: Wellmark IA HMO WHPI |
$17.80
|
| Rate for Payer: Wellmark IA PPO |
$17.80
|
|
|
LEVEL 1
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
CPT 99281 25
|
| Hospital Charge Code |
6922784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$80.55 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Aetna of IA Medicare |
$102.03
|
| Rate for Payer: Amerigroup Medicaid |
$103.25
|
| Rate for Payer: Amerigroup Medicare |
$81.36
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$80.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.24
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$80.55
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$103.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$92.63
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$105.61
|
|
|
LEVEL 1
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT 99281 25
|
| Hospital Charge Code |
6922784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
|
|
Level 1: Per Additional Intervals (30 Min)
|
Facility
|
OP
|
$89.00
|
|
| Hospital Charge Code |
1378485
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$40.05 |
| Max. Negotiated Rate |
$80.10 |
| Rate for Payer: Aetna of IA Commercial |
$80.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$80.10
|
| Rate for Payer: Aetna of IA Medicare |
$50.73
|
| Rate for Payer: Amerigroup Medicaid |
$51.34
|
| Rate for Payer: Amerigroup Medicare |
$40.45
|
| Rate for Payer: Cash Price |
$71.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$66.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$40.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$50.84
|
| Rate for Payer: Medical Associates Commercial |
$66.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$40.05
|
| Rate for Payer: Midlands Choice Commercial |
$62.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$51.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$46.06
|
| Rate for Payer: United Healthcare Commercial |
$80.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$52.51
|
|
|
Level 1: Per Additional Intervals (30 Min)
|
Facility
|
IP
|
$89.00
|
|
| Hospital Charge Code |
1378485
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$62.30 |
| Max. Negotiated Rate |
$80.10 |
| Rate for Payer: Aetna of IA Commercial |
$80.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$80.10
|
| Rate for Payer: Cash Price |
$71.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$66.75
|
| Rate for Payer: Medical Associates Commercial |
$66.75
|
| Rate for Payer: Midlands Choice Commercial |
$62.30
|
| Rate for Payer: United Healthcare Commercial |
$80.10
|
|
|
Level 2
|
Facility
|
OP
|
$2,300.00
|
|
| Hospital Charge Code |
1378486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,035.00 |
| Max. Negotiated Rate |
$2,070.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,070.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,070.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,311.00
|
| Rate for Payer: Amerigroup Medicaid |
$1,326.64
|
| Rate for Payer: Amerigroup Medicare |
$1,045.35
|
| Rate for Payer: Cash Price |
$1,840.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,725.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,035.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,313.76
|
| Rate for Payer: Medical Associates Commercial |
$1,725.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,035.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,610.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,333.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,190.25
|
| Rate for Payer: United Healthcare Commercial |
$2,070.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,357.00
|
|
|
Level 2
|
Facility
|
IP
|
$2,300.00
|
|
| Hospital Charge Code |
1378486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,610.00 |
| Max. Negotiated Rate |
$2,070.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,070.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,070.00
|
| Rate for Payer: Cash Price |
$1,840.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,725.00
|
| Rate for Payer: Medical Associates Commercial |
$1,725.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,610.00
|
| Rate for Payer: United Healthcare Commercial |
$2,070.00
|
|
|
LEVEL 2
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
CPT 99282 25
|
| Hospital Charge Code |
6922786
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$112.05 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna of IA Commercial |
$224.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$224.10
|
| Rate for Payer: Aetna of IA Medicare |
$141.93
|
| Rate for Payer: Amerigroup Medicaid |
$143.62
|
| Rate for Payer: Amerigroup Medicare |
$113.17
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$186.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$112.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$142.23
|
| Rate for Payer: Medical Associates Commercial |
$186.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$112.05
|
| Rate for Payer: Midlands Choice Commercial |
$174.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$144.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$128.86
|
| Rate for Payer: United Healthcare Commercial |
$224.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$146.91
|
|
