|
MNT INITIAL ASSESS EA 15 MIN
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 97802
|
| Hospital Charge Code |
5616789
|
|
Hospital Revenue Code
|
942
|
| 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
|
|
|
modafinil 100 mg Tab [VDMC]
|
Facility
|
OP
|
$3.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10610465
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna of IA Commercial |
$3.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.28
|
| Rate for Payer: Aetna of IA Medicare |
$2.07
|
| Rate for Payer: Amerigroup Medicaid |
$1.84
|
| Rate for Payer: Amerigroup Medicare |
$1.84
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.73
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.82
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.82
|
| Rate for Payer: Medical Associates Commercial |
$2.73
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.82
|
| Rate for Payer: Midlands Choice Commercial |
$2.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.85
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.85
|
| Rate for Payer: Oscar Health of IA Commercial |
$2.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.73
|
| Rate for Payer: United Healthcare Commercial |
$3.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.15
|
|
|
modafinil 100 mg Tab [VDMC]
|
Facility
|
IP
|
$3.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10610465
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna of IA Commercial |
$3.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.28
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.73
|
| Rate for Payer: Medical Associates Commercial |
$2.73
|
| Rate for Payer: Midlands Choice Commercial |
$2.55
|
| Rate for Payer: United Healthcare Commercial |
$3.28
|
|
|
MODIFIED BARIUM SWAL STUDY
|
Facility
|
IP
|
$447.00
|
|
|
Service Code
|
CPT 92611 GN
|
| Hospital Charge Code |
5530783
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$312.90 |
| Max. Negotiated Rate |
$402.30 |
| Rate for Payer: Aetna of IA Commercial |
$402.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$402.30
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$335.25
|
| Rate for Payer: Medical Associates Commercial |
$335.25
|
| Rate for Payer: Midlands Choice Commercial |
$312.90
|
| Rate for Payer: United Healthcare Commercial |
$402.30
|
|
|
MODIFIED BARIUM SWAL STUDY
|
Facility
|
OP
|
$447.00
|
|
|
Service Code
|
CPT 92611 GN
|
| Hospital Charge Code |
5530783
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$223.41 |
| Max. Negotiated Rate |
$402.30 |
| Rate for Payer: Aetna of IA Commercial |
$402.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$402.30
|
| Rate for Payer: Aetna of IA Medicare |
$254.79
|
| Rate for Payer: Amerigroup Medicaid |
$225.60
|
| Rate for Payer: Amerigroup Medicare |
$225.74
|
| Rate for Payer: Cash Price |
$357.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$335.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$223.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$223.41
|
| Rate for Payer: Medical Associates Commercial |
$335.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$223.50
|
| Rate for Payer: Midlands Choice Commercial |
$312.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$226.85
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$226.72
|
| Rate for Payer: Oscar Health of IA Commercial |
$335.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$335.25
|
| Rate for Payer: United Healthcare Commercial |
$402.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$263.73
|
|
|
MOD SEDAT ENDO SERVICE >5YRS
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
CPT G0500
|
| Hospital Charge Code |
8068958
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$37,116.00 |
| Rate for Payer: Aetna of IA Medicare |
$4.92
|
| Rate for Payer: Amerigroup Medicaid |
$5.09
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.02
|
| Rate for Payer: Medical Associates Commercial |
$8.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.92
|
| Rate for Payer: Midlands Choice Commercial |
$37,116.00
|
| Rate for Payer: Oscar Health of IA Commercial |
$8.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.38
|
|
|
MOD SED SAME PHYS/QHP <5 YRS
|
Professional
|
Both
|
$254.00
|
|
|
Service Code
|
CPT 99151
|
| Hospital Charge Code |
8068972
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$22.20 |
| Max. Negotiated Rate |
$177.80 |
| Rate for Payer: Aetna of IA Medicare |
$22.20
|
| Rate for Payer: Amerigroup Medicaid |
$22.95
|
| Rate for Payer: Cash Price |
$203.20
|
| Rate for Payer: Cash Price |
$203.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.64
|
| Rate for Payer: Medical Associates Commercial |
$42.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.20
|
| Rate for Payer: Midlands Choice Commercial |
$177.80
|
| Rate for Payer: Oscar Health of IA Commercial |
$39.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.30
|
|
|
MOD SED SAME PHYS/QHP 5/>YRS
|
Professional
|
Both
|
$169.00
|
|
|
Service Code
|
CPT 99152
|
| Hospital Charge Code |
8068979
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$21.33 |
| Rate for Payer: Aetna of IA Medicare |
$11.03
|
| Rate for Payer: Amerigroup Medicaid |
$11.41
|
| Rate for Payer: Cash Price |
$135.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.25
|
| Rate for Payer: Medical Associates Commercial |
$20.96
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.03
|
| Rate for Payer: Midlands Choice Commercial |
$21.33
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.54
|
|
|
MOD SED SAME PHYS/QHP EA
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
8069194
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Aetna of IA Medicare |
$10.16
|
| Rate for Payer: Amerigroup Medicaid |
$10.51
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.19
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.36
|
| Rate for Payer: Medical Associates Commercial |
$18.29
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.16
|
| Rate for Payer: Midlands Choice Commercial |
$25.20
|
| Rate for Payer: Oscar Health of IA Commercial |
$18.29
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.24
|
|
|
MODULAR HIP SYSTEM 155MM X 16MM
|
Facility
|
IP
|
$8,163.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8026267
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,714.10 |
| Max. Negotiated Rate |
$7,346.70 |
| Rate for Payer: Aetna of IA Commercial |
$7,346.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,346.70
|
| Rate for Payer: Cash Price |
$6,530.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,122.25
|
| Rate for Payer: Medical Associates Commercial |
$6,122.25
|
| Rate for Payer: Midlands Choice Commercial |
$5,714.10
|
| Rate for Payer: United Healthcare Commercial |
$7,346.70
|
|
|
MODULAR HIP SYSTEM 155MM X 16MM
|
Facility
|
OP
|
$8,163.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8026267
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,079.87 |
| Max. Negotiated Rate |
$7,346.70 |
| Rate for Payer: Aetna of IA Commercial |
$7,346.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,346.70
|
| Rate for Payer: Aetna of IA Medicare |
$4,652.91
|
| Rate for Payer: Amerigroup Medicaid |
$4,119.87
|
| Rate for Payer: Amerigroup Medicare |
$4,122.32
|
| Rate for Payer: Cash Price |
$6,530.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,122.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,081.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,079.87
|
| Rate for Payer: Medical Associates Commercial |
$6,122.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,081.50
|
| Rate for Payer: Midlands Choice Commercial |
$5,714.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,142.72
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$4,140.27
|
| Rate for Payer: Oscar Health of IA Commercial |
$6,122.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,122.25
|
| Rate for Payer: United Healthcare Commercial |
$7,346.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,816.17
|
|
|
MODULAR HIP SYSTEM 155MM X 18MM
|
Facility
|
IP
|
$8,163.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8026268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,714.10 |
| Max. Negotiated Rate |
$7,346.70 |
| Rate for Payer: Aetna of IA Commercial |
$7,346.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,346.70
|
| Rate for Payer: Cash Price |
$6,530.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,122.25
|
| Rate for Payer: Medical Associates Commercial |
$6,122.25
|
| Rate for Payer: Midlands Choice Commercial |
$5,714.10
|
| Rate for Payer: United Healthcare Commercial |
$7,346.70
|
|
|
MODULAR HIP SYSTEM 155MM X 18MM
|
Facility
|
OP
|
$8,163.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8026268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,079.87 |
| Max. Negotiated Rate |
$7,346.70 |
| Rate for Payer: Aetna of IA Commercial |
$7,346.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,346.70
|
| Rate for Payer: Aetna of IA Medicare |
$4,652.91
|
| Rate for Payer: Amerigroup Medicaid |
$4,119.87
|
| Rate for Payer: Amerigroup Medicare |
$4,122.32
|
| Rate for Payer: Cash Price |
$6,530.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,122.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,081.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,079.87
|
| Rate for Payer: Medical Associates Commercial |
$6,122.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,081.50
|
| Rate for Payer: Midlands Choice Commercial |
$5,714.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,142.72
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$4,140.27
|
| Rate for Payer: Oscar Health of IA Commercial |
$6,122.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,122.25
|
| Rate for Payer: United Healthcare Commercial |
$7,346.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,816.17
|
|
|
MODULAR HIP SYSTEM 17MM
|
Facility
|
OP
|
$8,311.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8046936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,153.84 |
| Max. Negotiated Rate |
$7,479.90 |
| Rate for Payer: Aetna of IA Commercial |
$7,479.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,479.90
|
| Rate for Payer: Aetna of IA Medicare |
$4,737.27
|
| Rate for Payer: Amerigroup Medicaid |
$4,194.56
|
| Rate for Payer: Amerigroup Medicare |
$4,197.06
|
| Rate for Payer: Cash Price |
$6,648.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,233.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,155.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,153.84
|
| Rate for Payer: Medical Associates Commercial |
$6,233.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,155.50
|
| Rate for Payer: Midlands Choice Commercial |
$5,817.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,217.83
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$4,215.34
|
| Rate for Payer: Oscar Health of IA Commercial |
$6,233.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,233.25
|
| Rate for Payer: United Healthcare Commercial |
$7,479.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,903.49
|
|
|
MODULAR HIP SYSTEM 17MM
|
Facility
|
IP
|
$8,311.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8046936
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,817.70 |
| Max. Negotiated Rate |
$7,479.90 |
| Rate for Payer: Aetna of IA Commercial |
$7,479.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,479.90
|
| Rate for Payer: Cash Price |
$6,648.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,233.25
|
| Rate for Payer: Medical Associates Commercial |
$6,233.25
|
| Rate for Payer: Midlands Choice Commercial |
$5,817.70
|
| Rate for Payer: United Healthcare Commercial |
$7,479.90
|
|
|
MODULAR HIP SYSTEM 195MM X 16MM
|
Facility
|
IP
|
$8,311.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8046935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,817.70 |
| Max. Negotiated Rate |
$7,479.90 |
| Rate for Payer: Aetna of IA Commercial |
$7,479.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,479.90
|
| Rate for Payer: Cash Price |
$6,648.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,233.25
|
| Rate for Payer: Medical Associates Commercial |
$6,233.25
|
| Rate for Payer: Midlands Choice Commercial |
$5,817.70
|
| Rate for Payer: United Healthcare Commercial |
$7,479.90
|
|
|
MODULAR HIP SYSTEM 195MM X 16MM
|
Facility
|
OP
|
$8,311.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8046935
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,153.84 |
| Max. Negotiated Rate |
$7,479.90 |
| Rate for Payer: Aetna of IA Commercial |
$7,479.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,479.90
|
| Rate for Payer: Aetna of IA Medicare |
$4,737.27
|
| Rate for Payer: Amerigroup Medicaid |
$4,194.56
|
| Rate for Payer: Amerigroup Medicare |
$4,197.06
|
| Rate for Payer: Cash Price |
$6,648.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,233.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,155.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,153.84
|
| Rate for Payer: Medical Associates Commercial |
$6,233.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,155.50
|
| Rate for Payer: Midlands Choice Commercial |
$5,817.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,217.83
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$4,215.34
|
| Rate for Payer: Oscar Health of IA Commercial |
$6,233.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,233.25
|
| Rate for Payer: United Healthcare Commercial |
$7,479.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,903.49
|
|
|
MODULAR HIP SYSTEM 195MM X 20MM
|
Facility
|
OP
|
$8,311.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8046937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,153.84 |
| Max. Negotiated Rate |
$7,479.90 |
| Rate for Payer: Aetna of IA Commercial |
$7,479.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,479.90
|
| Rate for Payer: Aetna of IA Medicare |
$4,737.27
|
| Rate for Payer: Amerigroup Medicaid |
$4,194.56
|
| Rate for Payer: Amerigroup Medicare |
$4,197.06
|
| Rate for Payer: Cash Price |
$6,648.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,233.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,155.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,153.84
|
| Rate for Payer: Medical Associates Commercial |
$6,233.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,155.50
|
| Rate for Payer: Midlands Choice Commercial |
$5,817.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,217.83
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$4,215.34
|
| Rate for Payer: Oscar Health of IA Commercial |
$6,233.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,233.25
|
| Rate for Payer: United Healthcare Commercial |
$7,479.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,903.49
|
|
|
MODULAR HIP SYSTEM 195MM X 20MM
|
Facility
|
IP
|
$8,311.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8046937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,817.70 |
| Max. Negotiated Rate |
$7,479.90 |
| Rate for Payer: Aetna of IA Commercial |
$7,479.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,479.90
|
| Rate for Payer: Cash Price |
$6,648.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,233.25
|
| Rate for Payer: Medical Associates Commercial |
$6,233.25
|
| Rate for Payer: Midlands Choice Commercial |
$5,817.70
|
| Rate for Payer: United Healthcare Commercial |
$7,479.90
|
|
|
mometasone Nasal 50 mcg/inh Spry [VDMC]
|
Facility
|
IP
|
$111.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406687
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$77.76 |
| Max. Negotiated Rate |
$99.97 |
| Rate for Payer: Aetna of IA Commercial |
$99.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.97
|
| Rate for Payer: Cash Price |
$88.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.31
|
| Rate for Payer: Medical Associates Commercial |
$83.31
|
| Rate for Payer: Midlands Choice Commercial |
$77.76
|
| Rate for Payer: United Healthcare Commercial |
$99.97
|
|
|
mometasone Nasal 50 mcg/inh Spry [VDMC]
|
Facility
|
OP
|
$111.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406687
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.52 |
| Max. Negotiated Rate |
$99.97 |
| Rate for Payer: Aetna of IA Commercial |
$99.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.97
|
| Rate for Payer: Aetna of IA Medicare |
$63.32
|
| Rate for Payer: Amerigroup Medicaid |
$56.06
|
| Rate for Payer: Amerigroup Medicare |
$56.10
|
| Rate for Payer: Cash Price |
$88.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.31
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.52
|
| Rate for Payer: Medical Associates Commercial |
$83.31
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.54
|
| Rate for Payer: Midlands Choice Commercial |
$77.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.37
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$56.34
|
| Rate for Payer: Oscar Health of IA Commercial |
$83.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.31
|
| Rate for Payer: United Healthcare Commercial |
$99.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.54
|
|
|
MONO-SPOT
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 86308
|
| Hospital Charge Code |
4022812
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
|
|
MONO-SPOT
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 86308
|
| Hospital Charge Code |
4022812
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$28.99 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Aetna of IA Medicare |
$33.06
|
| Rate for Payer: Amerigroup Medicaid |
$29.27
|
| Rate for Payer: Amerigroup Medicare |
$29.29
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.99
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.00
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.44
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$29.42
|
| Rate for Payer: Oscar Health of IA Commercial |
$43.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$43.50
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.22
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
montelukast 10 mg Tab [VDMC]
|
Facility
|
IP
|
$2.09
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406752
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of IA Commercial |
$1.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.88
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.57
|
| Rate for Payer: Medical Associates Commercial |
$1.57
|
| Rate for Payer: Midlands Choice Commercial |
$1.46
|
| Rate for Payer: United Healthcare Commercial |
$1.88
|
|
|
montelukast 10 mg Tab [VDMC]
|
Facility
|
OP
|
$2.09
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406752
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of IA Commercial |
$1.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.88
|
| Rate for Payer: Aetna of IA Medicare |
$1.19
|
| Rate for Payer: Amerigroup Medicaid |
$1.05
|
| Rate for Payer: Amerigroup Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.57
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.04
|
| Rate for Payer: Medical Associates Commercial |
$1.57
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.04
|
| Rate for Payer: Midlands Choice Commercial |
$1.46
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.06
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.06
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$1.88
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.23
|
|
