|
nitroglycerin 0.1 mg/hr Fil [VDMC]
|
Facility
|
OP
|
$9.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna of IA Commercial |
$8.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.90
|
| Rate for Payer: Aetna of IA Medicare |
$5.64
|
| Rate for Payer: Amerigroup Medicaid |
$4.99
|
| Rate for Payer: Amerigroup Medicare |
$4.99
|
| Rate for Payer: Cash Price |
$7.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.94
|
| Rate for Payer: Medical Associates Commercial |
$7.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.94
|
| Rate for Payer: Midlands Choice Commercial |
$6.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.02
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$5.02
|
| Rate for Payer: Oscar Health of IA Commercial |
$7.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.42
|
| Rate for Payer: United Healthcare Commercial |
$8.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.84
|
|
|
nitroglycerin 0.1 mg/hr Fil [VDMC]
|
Facility
|
IP
|
$9.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.92 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna of IA Commercial |
$8.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.90
|
| Rate for Payer: Cash Price |
$7.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.42
|
| Rate for Payer: Medical Associates Commercial |
$7.42
|
| Rate for Payer: Midlands Choice Commercial |
$6.92
|
| Rate for Payer: United Healthcare Commercial |
$8.90
|
|
|
nitroglycerin 0.2 mg/hr Transderm ER Film [VDMC]
|
Facility
|
OP
|
$10.05
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408877
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.02 |
| Max. Negotiated Rate |
$9.04 |
| Rate for Payer: Aetna of IA Commercial |
$9.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.04
|
| Rate for Payer: Aetna of IA Medicare |
$5.73
|
| Rate for Payer: Amerigroup Medicaid |
$5.07
|
| Rate for Payer: Amerigroup Medicare |
$5.08
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.02
|
| Rate for Payer: Medical Associates Commercial |
$7.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.02
|
| Rate for Payer: Midlands Choice Commercial |
$7.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.10
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$5.10
|
| Rate for Payer: Oscar Health of IA Commercial |
$7.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.54
|
| Rate for Payer: United Healthcare Commercial |
$9.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.93
|
|
|
nitroglycerin 0.2 mg/hr Transderm ER Film [VDMC]
|
Facility
|
IP
|
$10.05
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408877
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$9.04 |
| Rate for Payer: Aetna of IA Commercial |
$9.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.04
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.54
|
| Rate for Payer: Medical Associates Commercial |
$7.54
|
| Rate for Payer: Midlands Choice Commercial |
$7.04
|
| Rate for Payer: United Healthcare Commercial |
$9.04
|
|
|
nitroglycerin 0.4 mg Spr MDV [VDMC]
|
Facility
|
IP
|
$16.42
|
|
|
Service Code
|
NDC 45802-0210-01
|
| Hospital Charge Code |
22142517
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.49 |
| Max. Negotiated Rate |
$14.78 |
| Rate for Payer: Aetna of IA Commercial |
$14.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.78
|
| Rate for Payer: Cash Price |
$13.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.32
|
| Rate for Payer: Medical Associates Commercial |
$12.32
|
| Rate for Payer: Midlands Choice Commercial |
$11.49
|
| Rate for Payer: United Healthcare Commercial |
$14.78
|
|
|
nitroglycerin 0.4 mg Spr MDV [VDMC]
|
Facility
|
OP
|
$16.42
|
|
|
Service Code
|
NDC 45802-0210-01
|
| Hospital Charge Code |
22142517
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.21 |
| Max. Negotiated Rate |
$14.78 |
| Rate for Payer: Aetna of IA Commercial |
$14.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.78
|
| Rate for Payer: Aetna of IA Medicare |
$9.36
|
| Rate for Payer: Amerigroup Medicaid |
$8.29
|
| Rate for Payer: Amerigroup Medicare |
$8.29
|
| Rate for Payer: Cash Price |
$13.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.21
|
| Rate for Payer: Medical Associates Commercial |
$12.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.21
|
| Rate for Payer: Midlands Choice Commercial |
$11.49
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.33
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$8.33
|
| Rate for Payer: Oscar Health of IA Commercial |
$12.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.32
|
| Rate for Payer: United Healthcare Commercial |
$14.78
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.69
|
|
|
nitroglycerin 0.4 mg sublingual Tab [VDMC]
|
Facility
|
OP
|
$18.79
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408946
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$16.91 |
| Rate for Payer: Aetna of IA Commercial |
$16.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.91
|
| Rate for Payer: Aetna of IA Medicare |
$10.71
|
| Rate for Payer: Amerigroup Medicaid |
$9.48
|
| Rate for Payer: Amerigroup Medicare |
$9.49
|
| Rate for Payer: Cash Price |
$15.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.39
|
| Rate for Payer: Medical Associates Commercial |
$14.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.40
|
| Rate for Payer: Midlands Choice Commercial |
$13.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.54
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$9.53
|
| Rate for Payer: Oscar Health of IA Commercial |
$14.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.09
|
| Rate for Payer: United Healthcare Commercial |
$16.91
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.09
|
|
|
nitroglycerin 0.4 mg sublingual Tab [VDMC]
|
Facility
|
IP
|
$18.79
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408946
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.15 |
| Max. Negotiated Rate |
$16.91 |
| Rate for Payer: Aetna of IA Commercial |
$16.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.91
|
| Rate for Payer: Cash Price |
$15.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.09
|
| Rate for Payer: Medical Associates Commercial |
$14.09
|
| Rate for Payer: Midlands Choice Commercial |
$13.15
|
| Rate for Payer: United Healthcare Commercial |
$16.91
|
|
|
nitroglycerin 10 mg/100 mL-D5W IV Sol [VDMC]
|
Facility
|
OP
|
$125.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10409074
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.66 |
| Max. Negotiated Rate |
$112.83 |
| Rate for Payer: Aetna of IA Commercial |
$112.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$112.83
|
| Rate for Payer: Aetna of IA Medicare |
$71.46
|
| Rate for Payer: Amerigroup Medicaid |
$63.27
|
| Rate for Payer: Amerigroup Medicare |
$63.31
|
| Rate for Payer: Cash Price |
$100.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$94.03
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$62.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.66
|
| Rate for Payer: Medical Associates Commercial |
$94.03
|
| Rate for Payer: Medical Associates Managed Medicare |
$62.68
|
| Rate for Payer: Midlands Choice Commercial |
$87.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.63
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$63.59
|
| Rate for Payer: Oscar Health of IA Commercial |
$94.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$94.03
|
| Rate for Payer: United Healthcare Commercial |
$112.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$73.97
|
|
|
nitroglycerin 10 mg/100 mL-D5W IV Sol [VDMC]
|
Facility
|
IP
|
$125.37
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10409074
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$87.76 |
| Max. Negotiated Rate |
$112.83 |
| Rate for Payer: Aetna of IA Commercial |
$112.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$112.83
|
| Rate for Payer: Cash Price |
$100.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$94.03
|
| Rate for Payer: Medical Associates Commercial |
$94.03
|
| Rate for Payer: Midlands Choice Commercial |
$87.76
|
| Rate for Payer: United Healthcare Commercial |
$112.83
|
|
|
nitroglycerin 2% Top Oint [VDMC]
|
Facility
|
OP
|
$16.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436514
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.05 |
| Max. Negotiated Rate |
$14.50 |
| Rate for Payer: Aetna of IA Commercial |
$14.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.50
|
| Rate for Payer: Aetna of IA Medicare |
$9.18
|
| Rate for Payer: Amerigroup Medicaid |
$8.13
|
| Rate for Payer: Amerigroup Medicare |
$8.14
|
| Rate for Payer: Cash Price |
$12.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.05
|
| Rate for Payer: Medical Associates Commercial |
$12.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.06
|
| Rate for Payer: Midlands Choice Commercial |
$11.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.18
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$8.17
|
| Rate for Payer: Oscar Health of IA Commercial |
$12.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.08
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.50
|
|
|
nitroglycerin 2% Top Oint [VDMC]
|
Facility
|
IP
|
$16.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436514
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$14.50 |
| Rate for Payer: Medical Associates Commercial |
$12.08
|
| Rate for Payer: Aetna of IA Commercial |
$14.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.50
|
| Rate for Payer: Cash Price |
$12.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.08
|
| Rate for Payer: Midlands Choice Commercial |
$11.28
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
|
|
NM Bone Imaging Limited
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
CPT 78300
|
| Hospital Charge Code |
1169176
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$587.26 |
| Max. Negotiated Rate |
$1,057.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,057.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,057.50
|
| Rate for Payer: Aetna of IA Medicare |
$669.75
|
| Rate for Payer: Amerigroup Medicaid |
$593.02
|
| Rate for Payer: Amerigroup Medicare |
$593.38
|
| Rate for Payer: Cash Price |
$940.00
|
| Rate for Payer: Cash Price |
$940.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$881.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$587.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$587.26
|
| Rate for Payer: Medical Associates Commercial |
$881.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$587.50
|
| Rate for Payer: Midlands Choice Commercial |
$822.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$596.31
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$595.96
|
| Rate for Payer: Oscar Health of IA Commercial |
$881.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$881.25
|
| Rate for Payer: United Healthcare Commercial |
$1,057.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$693.25
|
| Rate for Payer: Wellmark IA HMO |
$879.16
|
| Rate for Payer: Wellmark IA PPO |
$967.08
|
|
|
NM Bone Imaging Limited
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
CPT 78300
|
| Hospital Charge Code |
1169176
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$822.50 |
| Max. Negotiated Rate |
$1,057.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,057.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,057.50
|
| Rate for Payer: Cash Price |
$940.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$881.25
|
| Rate for Payer: Medical Associates Commercial |
$881.25
|
| Rate for Payer: Midlands Choice Commercial |
$822.50
|
| Rate for Payer: United Healthcare Commercial |
$1,057.50
|
|
|
NM Bone Imaging Whole Body
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78306
|
| Hospital Charge Code |
1169180
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$719.21 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$726.26
|
| Rate for Payer: Amerigroup Medicare |
$726.70
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$719.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$719.21
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$719.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$730.29
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$729.86
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,079.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,079.25
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO |
$879.16
|
| Rate for Payer: Wellmark IA PPO |
$967.08
|
|
|
NM Bone Imaging Whole Body
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78306
|
| Hospital Charge Code |
1169180
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Bone Marrow Imaging Multiple Areas
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78305
|
| Hospital Charge Code |
1169184
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$719.21 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$726.26
|
| Rate for Payer: Amerigroup Medicare |
$726.70
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$719.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$719.21
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$719.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$730.29
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$729.86
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,079.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,079.25
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO |
$879.16
|
| Rate for Payer: Wellmark IA PPO |
$967.08
|
|
|
NM Bone Marrow Imaging Multiple Areas
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78305
|
| Hospital Charge Code |
1169184
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Bone Spect
|
Facility
|
IP
|
$2,452.00
|
|
|
Service Code
|
CPT 78320
|
| Hospital Charge Code |
1169188
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,716.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
|
|
NM Bone Spect
|
Facility
|
OP
|
$2,452.00
|
|
|
Service Code
|
CPT 78320
|
| Hospital Charge Code |
1169188
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,225.51 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Aetna of IA Medicare |
$1,397.64
|
| Rate for Payer: Amerigroup Medicaid |
$1,237.52
|
| Rate for Payer: Amerigroup Medicare |
$1,238.26
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,226.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,225.51
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,226.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,244.39
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1,243.65
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,839.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,839.00
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,446.68
|
|
|
NM Bone Three Phase Study
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
1169190
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$719.21 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$726.26
|
| Rate for Payer: Amerigroup Medicare |
$726.70
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$719.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$719.21
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$719.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$730.29
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$729.86
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,079.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,079.25
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO |
$879.16
|
| Rate for Payer: Wellmark IA PPO |
$967.08
|
|
|
NM Bone Three Phase Study
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
1169190
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Cardiac Blood Pool Gated Single
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78472
|
| Hospital Charge Code |
1169208
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$719.21 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$726.26
|
| Rate for Payer: Amerigroup Medicare |
$726.70
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$719.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$719.21
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$719.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$730.29
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$729.86
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,079.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,079.25
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO |
$879.16
|
| Rate for Payer: Wellmark IA PPO |
$967.08
|
|
|
NM Cardiac Blood Pool Gated Single
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78472
|
| Hospital Charge Code |
1169208
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Gastric Emptying Study
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78264
|
| Hospital Charge Code |
1169236
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
