|
Neurological Eye Disorders
|
Facility
IP
|
$8,433.97
|
|
|
Service Code
|
MS-DRG 123
|
| Hospital Charge Code |
12
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$8,433.97 |
| Rate for Payer: Amerigroup Medicaid |
$8,393.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,311.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,433.97
|
|
|
NEUROMUSCULAR ED PER 15 MIN
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
750905
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
NEUROMUSCULAR ED PER 15 MIN
|
Facility
OP
|
$114.00
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
750905
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$56.98 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$57.54
|
| Rate for Payer: Amerigroup Medicare |
$57.57
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.98
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.00
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
|
|
NEUROMUSCULAR RE-ED 15 MIN
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 97112 GP
|
| Hospital Charge Code |
1373913
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
NEUROMUSCULAR RE-ED 15 MIN
|
Facility
OP
|
$181.00
|
|
|
Service Code
|
CPT 97112 GN
|
| Hospital Charge Code |
7697845
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$90.46 |
| Max. Negotiated Rate |
$162.90 |
| Rate for Payer: Aetna of IA Commercial |
$162.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.90
|
| Rate for Payer: Aetna of IA Medicare |
$103.17
|
| Rate for Payer: Amerigroup Medicaid |
$91.35
|
| Rate for Payer: Amerigroup Medicare |
$91.40
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$90.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$90.46
|
| Rate for Payer: Medical Associates Commercial |
$135.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.50
|
| Rate for Payer: Midlands Choice Commercial |
$126.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$135.75
|
| Rate for Payer: United Healthcare Commercial |
$162.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.79
|
|
|
NEUROMUSCULAR RE-ED 15 MIN
|
Facility
IP
|
$181.00
|
|
|
Service Code
|
CPT 97112 GN
|
| Hospital Charge Code |
7697845
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$126.70 |
| Max. Negotiated Rate |
$162.90 |
| Rate for Payer: Aetna of IA Commercial |
$162.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.90
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.75
|
| Rate for Payer: Medical Associates Commercial |
$135.75
|
| Rate for Payer: Midlands Choice Commercial |
$126.70
|
| Rate for Payer: United Healthcare Commercial |
$162.90
|
|
|
NEUROMUSCULAR RE-ED 15 MIN
|
Facility
OP
|
$114.00
|
|
|
Service Code
|
CPT 97112 GP
|
| Hospital Charge Code |
1373913
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$56.98 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$57.54
|
| Rate for Payer: Amerigroup Medicare |
$57.57
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.98
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.00
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
|
|
Neuroses Except Depressive
|
Facility
IP
|
$4,957.63
|
|
|
Service Code
|
MS-DRG 882
|
| Hospital Charge Code |
612
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$4,957.63 |
| Rate for Payer: Amerigroup Medicaid |
$4,933.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,885.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,957.63
|
|
|
NEWBORN HEARING SCREEN
|
Facility
IP
|
$1,060.00
|
|
|
Service Code
|
CPT 92587
|
| Hospital Charge Code |
7290782
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$742.00 |
| Max. Negotiated Rate |
$954.00 |
| Rate for Payer: Aetna of IA Commercial |
$954.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$954.00
|
| Rate for Payer: Cash Price |
$848.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$795.00
|
| Rate for Payer: Medical Associates Commercial |
$795.00
|
| Rate for Payer: Midlands Choice Commercial |
$742.00
|
| Rate for Payer: United Healthcare Commercial |
$954.00
|
|
|
NEWBORN HEARING SCREEN
|
Facility
OP
|
$1,060.00
|
|
|
Service Code
|
CPT 92587
|
| Hospital Charge Code |
7290782
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$464.38 |
| Max. Negotiated Rate |
$954.00 |
| Rate for Payer: Aetna of IA Commercial |
$954.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$954.00
|
| Rate for Payer: Aetna of IA Medicare |
$604.20
|
| Rate for Payer: Amerigroup Medicaid |
$534.98
|
| Rate for Payer: Amerigroup Medicare |
$535.30
|
| Rate for Payer: Cash Price |
$848.00
|
| Rate for Payer: Cash Price |
$848.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$795.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$530.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$529.79
|
| Rate for Payer: Medical Associates Commercial |
$795.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$530.00
|
| Rate for Payer: Midlands Choice Commercial |
$742.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$537.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$795.00
|
| Rate for Payer: United Healthcare Commercial |
$954.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$625.40
|
| Rate for Payer: Wellmark IA HMO |
$464.38
|
| Rate for Payer: Wellmark IA PPO |
$510.82
|
|
|
NEW PATIENT COMPREHENSIVE
|
Professional
|
$679.00
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
8101313
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$166.48 |
| Max. Negotiated Rate |
$475.30 |
| Rate for Payer: Aetna of IA Medicare |
$166.48
|
| Rate for Payer: Amerigroup Medicaid |
$172.14
|
| Rate for Payer: Cash Price |
$543.20
|
| Rate for Payer: Cash Price |
$543.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$199.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$169.81
|
| Rate for Payer: Medical Associates Commercial |
$316.31
|
| Rate for Payer: Medical Associates Managed Medicare |
$166.48
|
| Rate for Payer: Midlands Choice Commercial |
$475.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$249.72
|
| Rate for Payer: United Healthcare Commercial |
$228.33
|
| Rate for Payer: Wellmark IA HMO |
$254.00
|
| Rate for Payer: Wellmark IA PPO |
$254.00
|
|
|
NEW PATIENT DETAILED
|
Professional
|
$540.00
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
8101312
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$122.51 |
| Max. Negotiated Rate |
$378.00 |
| Rate for Payer: Aetna of IA Medicare |
$122.51
|
| Rate for Payer: Amerigroup Medicaid |
$126.68
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$147.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$124.96
|
| Rate for Payer: Medical Associates Commercial |
$232.77
|
| Rate for Payer: Medical Associates Managed Medicare |
$122.51
|
| Rate for Payer: Midlands Choice Commercial |
$378.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$183.76
|
| Rate for Payer: United Healthcare Commercial |
$178.95
|
| Rate for Payer: Wellmark IA HMO |
$187.00
|
| Rate for Payer: Wellmark IA PPO |
$187.00
|
|
|
NEW PATIENT EXPANDED
|
Professional
|
$356.00
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
8101311
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$75.11 |
| Max. Negotiated Rate |
$249.20 |
| Rate for Payer: Aetna of IA Medicare |
$75.11
|
| Rate for Payer: Amerigroup Medicaid |
$77.66
|
| Rate for Payer: Cash Price |
$284.80
|
| Rate for Payer: Cash Price |
$284.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$90.13
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$76.61
|
| Rate for Payer: Medical Associates Commercial |
$142.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.11
|
| Rate for Payer: Midlands Choice Commercial |
$249.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.66
|
| Rate for Payer: United Healthcare Commercial |
$125.94
|
| Rate for Payer: Wellmark IA HMO |
$117.00
|
| Rate for Payer: Wellmark IA PPO |
$117.00
|
|
|
NEW PATIENT FOCUSED
|
Professional
|
$251.00
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
8101310
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$175.70 |
| Rate for Payer: Aetna of IA Medicare |
$43.61
|
| Rate for Payer: Amerigroup Medicaid |
$45.09
|
| Rate for Payer: Cash Price |
$200.80
|
| Rate for Payer: Cash Price |
$200.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.33
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$44.48
|
| Rate for Payer: Medical Associates Commercial |
$82.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$43.61
|
| Rate for Payer: Midlands Choice Commercial |
$175.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$65.42
|
| Rate for Payer: United Healthcare Commercial |
$84.63
|
| Rate for Payer: Wellmark IA HMO |
$68.00
|
| Rate for Payer: Wellmark IA PPO |
$68.00
|
|
|
Niacin 100 mg Tab
|
Facility
OP
|
$1.05
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702484
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of IA Commercial |
$0.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.95
|
| Rate for Payer: Aetna of IA Medicare |
$0.60
|
| Rate for Payer: Amerigroup Medicaid |
$0.53
|
| Rate for Payer: Amerigroup Medicare |
$0.53
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.79
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.53
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.52
|
| Rate for Payer: Medical Associates Commercial |
$0.79
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.53
|
| Rate for Payer: Midlands Choice Commercial |
$0.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.62
|
|
|
Niacin 100 mg Tab
|
Facility
IP
|
$1.05
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702484
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of IA Commercial |
$0.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.95
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.79
|
| Rate for Payer: Medical Associates Commercial |
$0.79
|
| Rate for Payer: Midlands Choice Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
niCARdipine 2.5 mg/mL 10ml Inj Sol
|
Facility
IP
|
$56.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.76 |
| Max. Negotiated Rate |
$51.12 |
| Rate for Payer: Aetna of IA Commercial |
$51.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.12
|
| Rate for Payer: Cash Price |
$45.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.60
|
| Rate for Payer: Medical Associates Commercial |
$42.60
|
| Rate for Payer: Midlands Choice Commercial |
$39.76
|
| Rate for Payer: United Healthcare Commercial |
$51.12
|
|
|
niCARdipine 2.5 mg/mL 10ml Inj Sol
|
Facility
OP
|
$56.80
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.39 |
| Max. Negotiated Rate |
$51.12 |
| Rate for Payer: Aetna of IA Commercial |
$51.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.12
|
| Rate for Payer: Aetna of IA Medicare |
$32.38
|
| Rate for Payer: Amerigroup Medicaid |
$28.67
|
| Rate for Payer: Amerigroup Medicare |
$28.68
|
| Rate for Payer: Cash Price |
$45.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.39
|
| Rate for Payer: Medical Associates Commercial |
$42.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.40
|
| Rate for Payer: Midlands Choice Commercial |
$39.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$28.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.60
|
| Rate for Payer: United Healthcare Commercial |
$51.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.51
|
|
|
nicotine 14 mg/24 hr Transderm ER Film
|
Facility
IP
|
$17.23
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$15.51 |
| Rate for Payer: Aetna of IA Commercial |
$15.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.51
|
| Rate for Payer: Cash Price |
$13.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.92
|
| Rate for Payer: Medical Associates Commercial |
$12.92
|
| Rate for Payer: Midlands Choice Commercial |
$12.06
|
| Rate for Payer: United Healthcare Commercial |
$15.51
|
|
|
nicotine 14 mg/24 hr Transderm ER Film
|
Facility
OP
|
$17.23
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702660
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.61 |
| Max. Negotiated Rate |
$15.51 |
| Rate for Payer: Aetna of IA Commercial |
$15.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.51
|
| Rate for Payer: Aetna of IA Medicare |
$9.82
|
| Rate for Payer: Amerigroup Medicaid |
$8.70
|
| Rate for Payer: Amerigroup Medicare |
$8.70
|
| Rate for Payer: Cash Price |
$13.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.62
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.61
|
| Rate for Payer: Medical Associates Commercial |
$12.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.62
|
| Rate for Payer: Midlands Choice Commercial |
$12.06
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.92
|
| Rate for Payer: United Healthcare Commercial |
$15.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.17
|
|
|
nicotine 21 mg/24 hr Transderm ER Film
|
Facility
IP
|
$15.82
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: Aetna of IA Commercial |
$14.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.24
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.86
|
| Rate for Payer: Medical Associates Commercial |
$11.86
|
| Rate for Payer: Midlands Choice Commercial |
$11.07
|
| Rate for Payer: United Healthcare Commercial |
$14.24
|
|
|
nicotine 21 mg/24 hr Transderm ER Film
|
Facility
OP
|
$15.82
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.91 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: Aetna of IA Commercial |
$14.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.24
|
| Rate for Payer: Aetna of IA Medicare |
$9.02
|
| Rate for Payer: Amerigroup Medicaid |
$7.98
|
| Rate for Payer: Amerigroup Medicare |
$7.99
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.91
|
| Rate for Payer: Medical Associates Commercial |
$11.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.91
|
| Rate for Payer: Midlands Choice Commercial |
$11.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.86
|
| Rate for Payer: United Healthcare Commercial |
$14.24
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.33
|
|
|
nicotine 7 mg/24 hr Transderm ER Film
|
Facility
OP
|
$12.81
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702658
|
|
Hospital Revenue Code
|
367
|
| Min. Negotiated Rate |
$6.40 |
| Max. Negotiated Rate |
$11.53 |
| Rate for Payer: Aetna of IA Commercial |
$11.53
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.53
|
| Rate for Payer: Aetna of IA Medicare |
$7.30
|
| Rate for Payer: Amerigroup Medicaid |
$6.47
|
| Rate for Payer: Amerigroup Medicare |
$6.47
|
| Rate for Payer: Cash Price |
$10.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.61
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.40
|
| Rate for Payer: Medical Associates Commercial |
$9.61
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.40
|
| Rate for Payer: Midlands Choice Commercial |
$8.97
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.61
|
| Rate for Payer: United Healthcare Commercial |
$11.53
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.56
|
|
|
nicotine 7 mg/24 hr Transderm ER Film
|
Facility
IP
|
$12.81
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702658
|
|
Hospital Revenue Code
|
367
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$11.53 |
| Rate for Payer: Aetna of IA Commercial |
$11.53
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.53
|
| Rate for Payer: Cash Price |
$10.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.61
|
| Rate for Payer: Medical Associates Commercial |
$9.61
|
| Rate for Payer: Midlands Choice Commercial |
$8.97
|
| Rate for Payer: United Healthcare Commercial |
$11.53
|
|
|
Nicotine and Metabolites UR DMCL
|
Facility
OP
|
$120.00
|
|
|
Service Code
|
CPT 80323
|
| Hospital Charge Code |
8822401
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna of IA Commercial |
$108.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$108.00
|
| Rate for Payer: Aetna of IA Medicare |
$68.40
|
| Rate for Payer: Amerigroup Medicaid |
$60.56
|
| Rate for Payer: Amerigroup Medicare |
$60.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$90.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$60.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.98
|
| Rate for Payer: Medical Associates Commercial |
$90.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$60.00
|
| Rate for Payer: Midlands Choice Commercial |
$84.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$90.00
|
| Rate for Payer: United Healthcare Commercial |
$108.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.80
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
