|
ACRYSOF IQ 21.0 LENS
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8891554
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOF IQ 21.5 LENS
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8885199
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
ACRYSOF IQ 21.5 LENS
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8885199
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOF IQ 22.5 LENS
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8885201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
ACRYSOF IQ 22.5 LENS
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8885201
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOF IQ 23.5 LENS
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8895998
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOF IQ 23.5 LENS
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8895998
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
ACRYSOF IQ 24.0 LENS
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8885205
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOF IQ 24.0 LENS
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8885205
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
ACRYSOF IQ 24.5 LENS AU00T0245
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8897429
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOF IQ 24.5 LENS AU00T0245
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8897429
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
ACRYSOF IQ 29.5 LENS
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8896000
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
ACRYSOF IQ 29.5 LENS
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8896000
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOF IQ LENS 23.0
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8885203
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
ACRYSOF IQ LENS 23.0
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8885203
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOF IQ PAN OPTIX TORIC 14.0
|
Facility
OP
|
$845.00
|
|
|
Service Code
|
CPT V2788
|
| Hospital Charge Code |
8891558
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$422.33 |
| Max. Negotiated Rate |
$760.50 |
| Rate for Payer: Aetna of IA Commercial |
$760.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$760.50
|
| Rate for Payer: Aetna of IA Medicare |
$481.65
|
| Rate for Payer: Amerigroup Medicaid |
$426.47
|
| Rate for Payer: Amerigroup Medicare |
$426.72
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$633.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$422.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$422.33
|
| Rate for Payer: Medical Associates Commercial |
$633.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$422.50
|
| Rate for Payer: Midlands Choice Commercial |
$591.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$428.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$633.75
|
| Rate for Payer: United Healthcare Commercial |
$760.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$498.55
|
|
|
ACRYSOF IQ PAN OPTIX TORIC 14.0
|
Facility
IP
|
$845.00
|
|
|
Service Code
|
CPT V2788
|
| Hospital Charge Code |
8891558
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$591.50 |
| Max. Negotiated Rate |
$760.50 |
| Rate for Payer: Aetna of IA Commercial |
$760.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$760.50
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$633.75
|
| Rate for Payer: Medical Associates Commercial |
$633.75
|
| Rate for Payer: Midlands Choice Commercial |
$591.50
|
| Rate for Payer: United Healthcare Commercial |
$760.50
|
|
|
ACRYSOF IQ TORIC IOL 14.5D
|
Facility
IP
|
$375.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8891556
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$337.50 |
| Rate for Payer: Aetna of IA Commercial |
$337.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$337.50
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$281.25
|
| Rate for Payer: Medical Associates Commercial |
$281.25
|
| Rate for Payer: Midlands Choice Commercial |
$262.50
|
| Rate for Payer: United Healthcare Commercial |
$337.50
|
|
|
ACRYSOF IQ TORIC IOL 14.5D
|
Facility
OP
|
$375.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8891556
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$187.42 |
| 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 |
$189.26
|
| Rate for Payer: Amerigroup Medicare |
$189.38
|
| 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 |
$187.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$187.42
|
| Rate for Payer: Medical Associates Commercial |
$281.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$187.50
|
| Rate for Payer: Midlands Choice Commercial |
$262.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$190.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$281.25
|
| Rate for Payer: United Healthcare Commercial |
$337.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$221.25
|
|
|
ACRYSOF IQ VIVITY TORIC 22.5 LENS
|
Facility
IP
|
$845.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8885211
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$591.50 |
| Max. Negotiated Rate |
$760.50 |
| Rate for Payer: Aetna of IA Commercial |
$760.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$760.50
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$633.75
|
| Rate for Payer: Medical Associates Commercial |
$633.75
|
| Rate for Payer: Midlands Choice Commercial |
$591.50
|
| Rate for Payer: United Healthcare Commercial |
$760.50
|
|
|
ACRYSOF IQ VIVITY TORIC 22.5 LENS
|
Facility
OP
|
$845.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8885211
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$422.33 |
| Max. Negotiated Rate |
$760.50 |
| Rate for Payer: Aetna of IA Commercial |
$760.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$760.50
|
| Rate for Payer: Aetna of IA Medicare |
$481.65
|
| Rate for Payer: Amerigroup Medicaid |
$426.47
|
| Rate for Payer: Amerigroup Medicare |
$426.72
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$633.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$422.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$422.33
|
| Rate for Payer: Medical Associates Commercial |
$633.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$422.50
|
| Rate for Payer: Midlands Choice Commercial |
$591.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$428.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$633.75
|
| Rate for Payer: United Healthcare Commercial |
$760.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$498.55
|
|
|
ACRYSOLF IQ LENS 21.5
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8893483
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
ACRYSOLF IQ LENS 21.5
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8893483
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
activated charcoal (ped) 25 g Oral Susp 120 mL
|
Facility
IP
|
$52.24
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43763158
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.57 |
| Max. Negotiated Rate |
$47.02 |
| Rate for Payer: Aetna of IA Commercial |
$47.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.02
|
| Rate for Payer: Cash Price |
$41.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.18
|
| Rate for Payer: Medical Associates Commercial |
$39.18
|
| Rate for Payer: Midlands Choice Commercial |
$36.57
|
| Rate for Payer: United Healthcare Commercial |
$47.02
|
|
|
activated charcoal (ped) 25 g Oral Susp 120 mL
|
Facility
OP
|
$52.24
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43763158
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.11 |
| Max. Negotiated Rate |
$47.02 |
| Rate for Payer: Aetna of IA Commercial |
$47.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.02
|
| Rate for Payer: Aetna of IA Medicare |
$29.78
|
| Rate for Payer: Amerigroup Medicaid |
$26.37
|
| Rate for Payer: Amerigroup Medicare |
$26.38
|
| Rate for Payer: Cash Price |
$41.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.11
|
| Rate for Payer: Medical Associates Commercial |
$39.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.12
|
| Rate for Payer: Midlands Choice Commercial |
$36.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.18
|
| Rate for Payer: United Healthcare Commercial |
$47.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.82
|
|
