|
N-Terminal pro Brain Natriuretic Peptide
|
Facility
OP
|
$231.00
|
|
|
Service Code
|
CPT 83880
|
| Hospital Charge Code |
1503769
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.92 |
| Max. Negotiated Rate |
$207.90 |
| Rate for Payer: Aetna of IA Commercial |
$207.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.90
|
| Rate for Payer: Aetna of IA Medicare |
$131.67
|
| Rate for Payer: Amerigroup Medicaid |
$116.59
|
| Rate for Payer: Amerigroup Medicare |
$116.66
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$173.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$115.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$115.45
|
| Rate for Payer: Medical Associates Commercial |
$173.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$115.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$117.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$173.25
|
| Rate for Payer: United Healthcare Commercial |
$207.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$136.29
|
| Rate for Payer: Wellmark IA HMO |
$102.92
|
| Rate for Payer: Wellmark IA PPO |
$113.21
|
|
|
N-Terminal pro Brain Natriuretic Peptide
|
Facility
IP
|
$231.00
|
|
|
Service Code
|
CPT 83880
|
| Hospital Charge Code |
1503769
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$207.90 |
| Rate for Payer: Aetna of IA Commercial |
$207.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.90
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$173.25
|
| Rate for Payer: Medical Associates Commercial |
$173.25
|
| Rate for Payer: Midlands Choice Commercial |
$161.70
|
| Rate for Payer: United Healthcare Commercial |
$207.90
|
|
|
NURSEMAIDS ELBOW CHILD
|
Professional
|
$388.00
|
|
|
Service Code
|
CPT 24640
|
| Hospital Charge Code |
7982808
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$74.56 |
| Max. Negotiated Rate |
$271.60 |
| Rate for Payer: Aetna of IA Medicare |
$74.56
|
| Rate for Payer: Amerigroup Medicaid |
$77.10
|
| Rate for Payer: Cash Price |
$310.40
|
| Rate for Payer: Cash Price |
$310.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$76.05
|
| Rate for Payer: Medical Associates Commercial |
$141.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$74.56
|
| Rate for Payer: Midlands Choice Commercial |
$271.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$111.84
|
| Rate for Payer: Wellmark IA HMO |
$152.00
|
| Rate for Payer: Wellmark IA PPO |
$179.00
|
|
|
nystatin 100000 units/mL Sus UD 5 mL
|
Facility
OP
|
$9.37
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$8.43 |
| Rate for Payer: Aetna of IA Commercial |
$8.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.43
|
| Rate for Payer: Aetna of IA Medicare |
$5.34
|
| Rate for Payer: Amerigroup Medicaid |
$4.73
|
| Rate for Payer: Amerigroup Medicare |
$4.73
|
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.03
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.68
|
| Rate for Payer: Medical Associates Commercial |
$7.03
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.68
|
| Rate for Payer: Midlands Choice Commercial |
$6.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.03
|
| Rate for Payer: United Healthcare Commercial |
$8.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.53
|
|
|
nystatin 100000 units/mL Sus UD 5 mL
|
Facility
IP
|
$9.37
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.56 |
| Max. Negotiated Rate |
$8.43 |
| Rate for Payer: Aetna of IA Commercial |
$8.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.43
|
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.03
|
| Rate for Payer: Medical Associates Commercial |
$7.03
|
| Rate for Payer: Midlands Choice Commercial |
$6.56
|
| Rate for Payer: United Healthcare Commercial |
$8.43
|
|
|
nystatin Top 100,000 units/g Crm 15 gm
|
Facility
OP
|
$22.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.30 |
| Max. Negotiated Rate |
$20.34 |
| Rate for Payer: Aetna of IA Commercial |
$20.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.34
|
| Rate for Payer: Aetna of IA Medicare |
$12.88
|
| Rate for Payer: Amerigroup Medicaid |
$11.41
|
| Rate for Payer: Amerigroup Medicare |
$11.41
|
| Rate for Payer: Cash Price |
$18.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.30
|
| Rate for Payer: Medical Associates Commercial |
$16.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.30
|
| Rate for Payer: Midlands Choice Commercial |
$15.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.95
|
| Rate for Payer: United Healthcare Commercial |
$20.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.33
|
|
|
nystatin Top 100,000 units/g Crm 15 gm
|
Facility
IP
|
$22.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$20.34 |
| Rate for Payer: Aetna of IA Commercial |
$20.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.34
|
| Rate for Payer: Cash Price |
$18.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.95
|
| Rate for Payer: Medical Associates Commercial |
$16.95
|
| Rate for Payer: Midlands Choice Commercial |
$15.82
|
| Rate for Payer: United Healthcare Commercial |
$20.34
|
|
|
nystatin Top 100,000 units/g Oint 15 gm
|
Facility
IP
|
$19.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701840
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$17.64 |
| Rate for Payer: Aetna of IA Commercial |
$17.64
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$17.64
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.70
|
| Rate for Payer: Medical Associates Commercial |
$14.70
|
| Rate for Payer: Midlands Choice Commercial |
$13.72
|
| Rate for Payer: United Healthcare Commercial |
$17.64
|
|
|
nystatin Top 100,000 units/g Oint 15 gm
|
Facility
OP
|
$19.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701840
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$17.64 |
| Rate for Payer: Aetna of IA Commercial |
$17.64
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$17.64
|
| Rate for Payer: Aetna of IA Medicare |
$11.17
|
| Rate for Payer: Amerigroup Medicaid |
$9.89
|
| Rate for Payer: Amerigroup Medicare |
$9.90
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.80
|
| Rate for Payer: Medical Associates Commercial |
$14.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.80
|
| Rate for Payer: Midlands Choice Commercial |
$13.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.70
|
| Rate for Payer: United Healthcare Commercial |
$17.64
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.56
|
|
|
nystatin Top 100,000 units/g Pwdr 15 gm
|
Facility
OP
|
$48.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705993
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$43.31 |
| Rate for Payer: Aetna of IA Commercial |
$43.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.31
|
| Rate for Payer: Aetna of IA Medicare |
$27.43
|
| Rate for Payer: Amerigroup Medicaid |
$24.29
|
| Rate for Payer: Amerigroup Medicare |
$24.30
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.05
|
| Rate for Payer: Medical Associates Commercial |
$36.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.06
|
| Rate for Payer: Midlands Choice Commercial |
$33.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.09
|
| Rate for Payer: United Healthcare Commercial |
$43.31
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.39
|
|
|
nystatin Top 100,000 units/g Pwdr 15 gm
|
Facility
IP
|
$48.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705993
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.68 |
| Max. Negotiated Rate |
$43.31 |
| Rate for Payer: Aetna of IA Commercial |
$43.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.31
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.09
|
| Rate for Payer: Medical Associates Commercial |
$36.09
|
| Rate for Payer: Midlands Choice Commercial |
$33.68
|
| Rate for Payer: United Healthcare Commercial |
$43.31
|
|
|
Occ Health Pre Work Screen
|
Facility
OP
|
$75.00
|
|
| Hospital Charge Code |
8782365
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$37.48 |
| Max. Negotiated Rate |
$67.50 |
| Rate for Payer: Aetna of IA Commercial |
$67.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$67.50
|
| Rate for Payer: Aetna of IA Medicare |
$42.75
|
| Rate for Payer: Amerigroup Medicaid |
$37.85
|
| Rate for Payer: Amerigroup Medicare |
$37.88
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$56.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$37.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.48
|
| Rate for Payer: Medical Associates Commercial |
$56.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$37.50
|
| Rate for Payer: Midlands Choice Commercial |
$52.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.25
|
| Rate for Payer: United Healthcare Commercial |
$67.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$44.25
|
|
|
Occ Health Pre Work Screen
|
Facility
IP
|
$75.00
|
|
| Hospital Charge Code |
8782365
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$67.50 |
| Rate for Payer: Aetna of IA Commercial |
$67.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$67.50
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$56.25
|
| Rate for Payer: Medical Associates Commercial |
$56.25
|
| Rate for Payer: Midlands Choice Commercial |
$52.50
|
| Rate for Payer: United Healthcare Commercial |
$67.50
|
|
|
OCCULT BLOOD OTHER
|
Facility
IP
|
$41.00
|
|
|
Service Code
|
CPT 82271
|
| Hospital Charge Code |
4022862
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna of IA Commercial |
$36.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.90
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.75
|
| Rate for Payer: Medical Associates Commercial |
$30.75
|
| Rate for Payer: Midlands Choice Commercial |
$28.70
|
| Rate for Payer: United Healthcare Commercial |
$36.90
|
|
|
OCCULT BLOOD OTHER
|
Facility
OP
|
$41.00
|
|
|
Service Code
|
CPT 82271
|
| Hospital Charge Code |
4022862
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna of IA Commercial |
$36.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.90
|
| Rate for Payer: Aetna of IA Medicare |
$23.37
|
| Rate for Payer: Amerigroup Medicaid |
$20.69
|
| Rate for Payer: Amerigroup Medicare |
$20.70
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.49
|
| Rate for Payer: Medical Associates Commercial |
$30.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.50
|
| Rate for Payer: Midlands Choice Commercial |
$28.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.75
|
| Rate for Payer: United Healthcare Commercial |
$36.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.19
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
OCCULT-BLOOD-STOOL
|
Facility
OP
|
$65.00
|
|
|
Service Code
|
CPT G0328
|
| Hospital Charge Code |
4022859
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.49 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Aetna of IA Medicare |
$37.05
|
| Rate for Payer: Amerigroup Medicaid |
$32.81
|
| Rate for Payer: Amerigroup Medicare |
$32.82
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.49
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.50
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$48.75
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.35
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
OCCULT-BLOOD-STOOL
|
Facility
IP
|
$65.00
|
|
|
Service Code
|
CPT G0328
|
| Hospital Charge Code |
4022859
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
|
|
octreotide 100 mcg/mL
|
Facility
OP
|
$30.21
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
43700573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.10 |
| Max. Negotiated Rate |
$27.19 |
| Rate for Payer: Aetna of IA Commercial |
$27.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.19
|
| Rate for Payer: Aetna of IA Medicare |
$17.22
|
| Rate for Payer: Amerigroup Medicaid |
$15.25
|
| Rate for Payer: Amerigroup Medicare |
$15.26
|
| Rate for Payer: Cash Price |
$24.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.10
|
| Rate for Payer: Medical Associates Commercial |
$22.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.10
|
| Rate for Payer: Midlands Choice Commercial |
$21.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.66
|
| Rate for Payer: United Healthcare Commercial |
$27.19
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.82
|
|
|
octreotide 100 mcg/mL
|
Facility
IP
|
$30.21
|
|
|
Service Code
|
CPT J2354
|
| Hospital Charge Code |
43700573
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.15 |
| Max. Negotiated Rate |
$27.19 |
| Rate for Payer: Aetna of IA Commercial |
$27.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.19
|
| Rate for Payer: Cash Price |
$24.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.66
|
| Rate for Payer: Medical Associates Commercial |
$22.66
|
| Rate for Payer: Midlands Choice Commercial |
$21.15
|
| Rate for Payer: United Healthcare Commercial |
$27.19
|
|
|
Octreotide Acetate 20 mg Pow SDV
|
Facility
IP
|
$7,972.72
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
43700322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,580.90 |
| Max. Negotiated Rate |
$7,175.45 |
| Rate for Payer: Aetna of IA Commercial |
$7,175.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,175.45
|
| Rate for Payer: Cash Price |
$6,378.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5,979.54
|
| Rate for Payer: Medical Associates Commercial |
$5,979.54
|
| Rate for Payer: Midlands Choice Commercial |
$5,580.90
|
| Rate for Payer: United Healthcare Commercial |
$7,175.45
|
|
|
Octreotide Acetate 20 mg Pow SDV
|
Facility
OP
|
$7,972.72
|
|
|
Service Code
|
CPT J2353
|
| Hospital Charge Code |
43700322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,984.77 |
| Max. Negotiated Rate |
$7,175.45 |
| Rate for Payer: Aetna of IA Commercial |
$7,175.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,175.45
|
| Rate for Payer: Aetna of IA Medicare |
$4,544.45
|
| Rate for Payer: Amerigroup Medicaid |
$4,023.83
|
| Rate for Payer: Amerigroup Medicare |
$4,026.22
|
| Rate for Payer: Cash Price |
$6,378.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5,979.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,986.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,984.77
|
| Rate for Payer: Medical Associates Commercial |
$5,979.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,986.36
|
| Rate for Payer: Midlands Choice Commercial |
$5,580.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,046.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$5,979.54
|
| Rate for Payer: United Healthcare Commercial |
$7,175.45
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,703.90
|
|
|
Ocular lubricant preserved drops Sol 15ml
|
Facility
IP
|
$21.88
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700207
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.32 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna of IA Commercial |
$19.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.69
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.41
|
| Rate for Payer: Medical Associates Commercial |
$16.41
|
| Rate for Payer: Midlands Choice Commercial |
$15.32
|
| Rate for Payer: United Healthcare Commercial |
$19.69
|
|
|
Ocular lubricant preserved drops Sol 15ml
|
Facility
OP
|
$21.88
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700207
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.94 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna of IA Commercial |
$19.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.69
|
| Rate for Payer: Aetna of IA Medicare |
$12.47
|
| Rate for Payer: Amerigroup Medicaid |
$11.04
|
| Rate for Payer: Amerigroup Medicare |
$11.05
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.41
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.94
|
| Rate for Payer: Medical Associates Commercial |
$16.41
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.94
|
| Rate for Payer: Midlands Choice Commercial |
$15.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.41
|
| Rate for Payer: United Healthcare Commercial |
$19.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$12.91
|
|
|
ofloxacin ophthalmic 0.3% 5ml drops
|
Facility
OP
|
$25.32
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.65 |
| Max. Negotiated Rate |
$22.79 |
| Rate for Payer: Aetna of IA Commercial |
$22.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.79
|
| Rate for Payer: Aetna of IA Medicare |
$14.43
|
| Rate for Payer: Amerigroup Medicaid |
$12.78
|
| Rate for Payer: Amerigroup Medicare |
$12.79
|
| Rate for Payer: Cash Price |
$20.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.99
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.65
|
| Rate for Payer: Medical Associates Commercial |
$18.99
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.66
|
| Rate for Payer: Midlands Choice Commercial |
$17.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.99
|
| Rate for Payer: United Healthcare Commercial |
$22.79
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.94
|
|
|
ofloxacin ophthalmic 0.3% 5ml drops
|
Facility
IP
|
$25.32
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705882
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$22.79 |
| Rate for Payer: Aetna of IA Commercial |
$22.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.79
|
| Rate for Payer: Cash Price |
$20.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.99
|
| Rate for Payer: Medical Associates Commercial |
$18.99
|
| Rate for Payer: Midlands Choice Commercial |
$17.72
|
| Rate for Payer: United Healthcare Commercial |
$22.79
|
|
