|
MG Mammogram Digital Screening Left.
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52|LT
|
| Hospital Charge Code |
4570784
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Aetna of IA Medicare |
$172.14
|
| Rate for Payer: Amerigroup Medicaid |
$174.19
|
| Rate for Payer: Amerigroup Medicare |
$137.26
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.90
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$175.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$156.28
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
| Rate for Payer: Wellmark IA HMO WHPI |
$197.81
|
| Rate for Payer: Wellmark IA PPO |
$217.90
|
|
|
MG Mammogram Digital Screening Right.
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
4570787
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$211.40 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Right.
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
4570787
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Aetna of IA Medicare |
$172.14
|
| Rate for Payer: Amerigroup Medicaid |
$174.19
|
| Rate for Payer: Amerigroup Medicare |
$137.26
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.90
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$175.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$156.28
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
| Rate for Payer: Wellmark IA HMO WHPI |
$197.81
|
| Rate for Payer: Wellmark IA PPO |
$217.90
|
|
|
miconazole Top 2% Crm 15gm [VDMC]
|
Facility
|
IP
|
$16.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Aetna of IA Commercial |
$14.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.41
|
| Rate for Payer: Cash Price |
$12.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.01
|
| Rate for Payer: Medical Associates Commercial |
$12.01
|
| Rate for Payer: Midlands Choice Commercial |
$11.21
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
|
|
miconazole Top 2% Crm 15gm [VDMC]
|
Facility
|
OP
|
$16.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.21 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Aetna of IA Commercial |
$14.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.41
|
| Rate for Payer: Aetna of IA Medicare |
$9.13
|
| Rate for Payer: Amerigroup Medicaid |
$9.24
|
| Rate for Payer: Amerigroup Medicare |
$7.28
|
| Rate for Payer: Cash Price |
$12.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.15
|
| Rate for Payer: Medical Associates Commercial |
$12.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.21
|
| Rate for Payer: Midlands Choice Commercial |
$11.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.29
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.45
|
|
|
miconazole topical 2% Cre 45 gm [VDMC]
|
Facility
|
IP
|
$43.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$39.08 |
| Rate for Payer: Aetna of IA Commercial |
$39.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.08
|
| Rate for Payer: Cash Price |
$34.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.57
|
| Rate for Payer: Medical Associates Commercial |
$32.57
|
| Rate for Payer: Midlands Choice Commercial |
$30.40
|
| Rate for Payer: United Healthcare Commercial |
$39.08
|
|
|
miconazole topical 2% Cre 45 gm [VDMC]
|
Facility
|
OP
|
$43.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.54 |
| Max. Negotiated Rate |
$39.08 |
| Rate for Payer: Aetna of IA Commercial |
$39.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.08
|
| Rate for Payer: Aetna of IA Medicare |
$24.75
|
| Rate for Payer: Amerigroup Medicaid |
$25.05
|
| Rate for Payer: Amerigroup Medicare |
$19.74
|
| Rate for Payer: Cash Price |
$34.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.57
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.80
|
| Rate for Payer: Medical Associates Commercial |
$32.57
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.54
|
| Rate for Payer: Midlands Choice Commercial |
$30.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.47
|
| Rate for Payer: United Healthcare Commercial |
$39.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.62
|
|
|
Micro-Invasive Glaucoma Surgery
|
Facility
|
OP
|
$10,570.84
|
|
|
Service Code
|
CPT 66991
|
| Min. Negotiated Rate |
$9,596.32 |
| Max. Negotiated Rate |
$10,570.84 |
| Rate for Payer: Wellmark IA HMO WHPI |
$9,596.32
|
| Rate for Payer: Wellmark IA PPO |
$10,570.84
|
|
|
midazolam 1 mg/mL 2 ML SDV [VDMC]
|
Facility
|
OP
|
$41.09
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10406011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.49 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$36.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.98
|
| Rate for Payer: Aetna of IA Medicare |
$23.42
|
| Rate for Payer: Amerigroup Medicaid |
$23.70
|
| Rate for Payer: Amerigroup Medicare |
$18.67
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.82
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.47
|
| Rate for Payer: Medical Associates Commercial |
$30.82
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.49
|
| Rate for Payer: Midlands Choice Commercial |
$28.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.26
|
| Rate for Payer: United Healthcare Commercial |
$36.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.24
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
midazolam 1 mg/mL 2 ML SDV [VDMC]
|
Facility
|
IP
|
$41.09
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10406011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.76 |
| Max. Negotiated Rate |
$36.98 |
| Rate for Payer: Aetna of IA Commercial |
$36.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.98
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.82
|
| Rate for Payer: Medical Associates Commercial |
$30.82
|
| Rate for Payer: Midlands Choice Commercial |
$28.76
|
| Rate for Payer: United Healthcare Commercial |
$36.98
|
|
|
midazolam 1 mg/mL Inj 5 ML SDV [VDMC]
|
Facility
|
OP
|
$42.87
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10405940
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$38.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.58
|
| Rate for Payer: Aetna of IA Medicare |
$24.44
|
| Rate for Payer: Amerigroup Medicaid |
$24.73
|
| Rate for Payer: Amerigroup Medicare |
$19.49
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.29
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.49
|
| Rate for Payer: Medical Associates Commercial |
$32.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.29
|
| Rate for Payer: Midlands Choice Commercial |
$30.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.19
|
| Rate for Payer: United Healthcare Commercial |
$38.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.29
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
midazolam 1 mg/mL Inj 5 ML SDV [VDMC]
|
Facility
|
IP
|
$42.87
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10405940
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.01 |
| Max. Negotiated Rate |
$38.58 |
| Rate for Payer: Aetna of IA Commercial |
$38.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.58
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.15
|
| Rate for Payer: Medical Associates Commercial |
$32.15
|
| Rate for Payer: Midlands Choice Commercial |
$30.01
|
| Rate for Payer: United Healthcare Commercial |
$38.58
|
|
|
midazolam 1 mg/mL MDV 5 ML vial [VDMC]
|
Facility
|
OP
|
$43.61
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
13683949
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.63 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$39.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.25
|
| Rate for Payer: Aetna of IA Medicare |
$24.86
|
| Rate for Payer: Amerigroup Medicaid |
$25.16
|
| Rate for Payer: Amerigroup Medicare |
$19.82
|
| Rate for Payer: Cash Price |
$34.89
|
| Rate for Payer: Cash Price |
$34.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.91
|
| Rate for Payer: Medical Associates Commercial |
$32.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.63
|
| Rate for Payer: Midlands Choice Commercial |
$30.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.57
|
| Rate for Payer: United Healthcare Commercial |
$39.25
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.73
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
midazolam 1 mg/mL MDV 5 ML vial [VDMC]
|
Facility
|
IP
|
$43.61
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
13683949
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.53 |
| Max. Negotiated Rate |
$39.25 |
| Rate for Payer: Aetna of IA Commercial |
$39.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.25
|
| Rate for Payer: Cash Price |
$34.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.71
|
| Rate for Payer: Medical Associates Commercial |
$32.71
|
| Rate for Payer: Midlands Choice Commercial |
$30.53
|
| Rate for Payer: United Healthcare Commercial |
$39.25
|
|
|
midazolam 2 mg/mL Oral Syrup [VDMC]
|
Facility
|
OP
|
$10.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$9.01 |
| Rate for Payer: Aetna of IA Commercial |
$9.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.01
|
| Rate for Payer: Aetna of IA Medicare |
$5.70
|
| Rate for Payer: Amerigroup Medicaid |
$5.77
|
| Rate for Payer: Amerigroup Medicare |
$4.55
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.72
|
| Rate for Payer: Medical Associates Commercial |
$7.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.50
|
| Rate for Payer: Midlands Choice Commercial |
$7.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.18
|
| Rate for Payer: United Healthcare Commercial |
$9.01
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.90
|
|
|
midazolam 2 mg/mL Oral Syrup [VDMC]
|
Facility
|
IP
|
$10.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$9.01 |
| Rate for Payer: Aetna of IA Commercial |
$9.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.01
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.51
|
| Rate for Payer: Medical Associates Commercial |
$7.51
|
| Rate for Payer: Midlands Choice Commercial |
$7.00
|
| Rate for Payer: United Healthcare Commercial |
$9.01
|
|
|
midodrine 5 mg Tab [VDMC]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Midlands Choice Commercial |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
|
|
midodrine 5 mg Tab [VDMC]
|
Facility
|
OP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Aetna of IA Medicare |
$1.28
|
| Rate for Payer: Amerigroup Medicaid |
$1.30
|
| Rate for Payer: Amerigroup Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.28
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.01
|
| Rate for Payer: Midlands Choice Commercial |
$1.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
|
MILEAGE GROUND PER 10TH OF A MILE
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS A0425 QN
|
| Hospital Charge Code |
5966784
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of IA Commercial |
$1.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.80
|
| Rate for Payer: Aetna of IA Medicare |
$1.14
|
| Rate for Payer: Amerigroup Medicaid |
$1.15
|
| Rate for Payer: Amerigroup Medicare |
$0.91
|
| Rate for Payer: Cash Price |
$1.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.14
|
| Rate for Payer: Medical Associates Commercial |
$1.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.90
|
| Rate for Payer: Midlands Choice Commercial |
$1.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.04
|
| Rate for Payer: United Healthcare Commercial |
$1.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.70
|
|
|
MILEAGE GROUND PER 10TH OF A MILE
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS A0425 QN
|
| Hospital Charge Code |
5966784
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of IA Commercial |
$1.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.80
|
| Rate for Payer: Cash Price |
$1.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.50
|
| Rate for Payer: Medical Associates Commercial |
$1.50
|
| Rate for Payer: Midlands Choice Commercial |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.80
|
|
|
MINI 4 HOLE ST
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$93.10 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of IA Commercial |
$119.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$119.70
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$99.75
|
| Rate for Payer: Medical Associates Commercial |
$99.75
|
| Rate for Payer: Midlands Choice Commercial |
$93.10
|
| Rate for Payer: United Healthcare Commercial |
$119.70
|
|
|
MINI 4 HOLE ST
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$59.85 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of IA Commercial |
$119.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$119.70
|
| Rate for Payer: Aetna of IA Medicare |
$75.81
|
| Rate for Payer: Amerigroup Medicaid |
$76.71
|
| Rate for Payer: Amerigroup Medicare |
$60.45
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$99.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$59.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$75.97
|
| Rate for Payer: Medical Associates Commercial |
$99.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.85
|
| Rate for Payer: Midlands Choice Commercial |
$93.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$77.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$68.83
|
| Rate for Payer: United Healthcare Commercial |
$119.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$78.47
|
|
|
MINOR BLADDER PROCEDURES WITH CC
|
Facility
|
IP
|
$10,535.77
|
|
|
Service Code
|
MSDRG 663
|
| Min. Negotiated Rate |
$10,383.07 |
| Max. Negotiated Rate |
$10,535.77 |
| Rate for Payer: Amerigroup Medicaid |
$10,484.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10,383.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,535.77
|
|
|
MINOR BLADDER PROCEDURES WITH MCC
|
Facility
|
IP
|
$32,997.88
|
|
|
Service Code
|
MSDRG 662
|
| Min. Negotiated Rate |
$32,519.64 |
| Max. Negotiated Rate |
$32,997.88 |
| Rate for Payer: Amerigroup Medicaid |
$32,838.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32,519.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32,997.88
|
|
|
MINOR BLADDER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$10,535.77
|
|
|
Service Code
|
MSDRG 664
|
| Min. Negotiated Rate |
$10,383.07 |
| Max. Negotiated Rate |
$10,535.77 |
| Rate for Payer: Amerigroup Medicaid |
$10,484.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10,383.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,535.77
|
|
