|
Other Skin, Subcutaneous Tissue and Breast Procedures Without CC/MCC
|
Facility
IP
|
$8,640.66
|
|
|
Service Code
|
MS-DRG 581
|
| Hospital Charge Code |
385
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$8,640.66 |
| Rate for Payer: Amerigroup Medicaid |
$8,598.91
|
| 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 |
$8,515.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,640.66
|
|
|
Other Vascular Procedures With CC
|
Facility
IP
|
$24,177.89
|
|
|
Service Code
|
MS-DRG 253
|
| Hospital Charge Code |
115
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$24,177.89 |
| Rate for Payer: Amerigroup Medicaid |
$24,061.09
|
| 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 |
$23,827.49
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24,177.89
|
|
|
Other Vascular Procedures With MCC
|
Facility
IP
|
$32,664.02
|
|
|
Service Code
|
MS-DRG 252
|
| Hospital Charge Code |
114
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$32,664.02 |
| Rate for Payer: Amerigroup Medicaid |
$32,506.22
|
| 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 |
$32,190.63
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32,664.02
|
|
|
Other Vascular Procedures Without CC/MCC
|
Facility
IP
|
$14,973.26
|
|
|
Service Code
|
MS-DRG 254
|
| Hospital Charge Code |
116
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$14,973.26 |
| Rate for Payer: Amerigroup Medicaid |
$14,900.93
|
| 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 |
$14,756.26
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14,973.26
|
|
|
Otitis Media and URI With MCC
|
Facility
IP
|
$5,385.77
|
|
|
Service Code
|
MS-DRG 152
|
| Hospital Charge Code |
32
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$5,385.77 |
| Rate for Payer: Amerigroup Medicaid |
$5,359.75
|
| 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 |
$5,307.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,385.77
|
|
|
Otitis Media and URI Without MCC
|
Facility
IP
|
$4,372.01
|
|
|
Service Code
|
MS-DRG 153
|
| Hospital Charge Code |
33
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$4,372.01 |
| Rate for Payer: Amerigroup Medicaid |
$4,350.88
|
| 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 |
$4,308.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,372.01
|
|
|
OT RE-EVAL EST PLAN CARE
|
Facility
OP
|
$153.00
|
|
|
Service Code
|
CPT 97168 GO
|
| Hospital Charge Code |
8397283
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$76.47 |
| Max. Negotiated Rate |
$137.70 |
| Rate for Payer: Aetna of IA Commercial |
$137.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$137.70
|
| Rate for Payer: Aetna of IA Medicare |
$87.21
|
| Rate for Payer: Amerigroup Medicaid |
$77.22
|
| Rate for Payer: Amerigroup Medicare |
$77.26
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$76.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$76.47
|
| Rate for Payer: Medical Associates Commercial |
$114.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$76.50
|
| Rate for Payer: Midlands Choice Commercial |
$107.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$77.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$114.75
|
| Rate for Payer: United Healthcare Commercial |
$137.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$90.27
|
|
|
OT RE-EVAL EST PLAN CARE
|
Facility
IP
|
$153.00
|
|
|
Service Code
|
CPT 97168 GO
|
| Hospital Charge Code |
8397283
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$137.70 |
| Rate for Payer: Aetna of IA Commercial |
$137.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$137.70
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.75
|
| Rate for Payer: Medical Associates Commercial |
$114.75
|
| Rate for Payer: Midlands Choice Commercial |
$107.10
|
| Rate for Payer: United Healthcare Commercial |
$137.70
|
|
|
OT Wheelchair Training Charges
|
Facility
IP
|
$85.00
|
|
|
Service Code
|
CPT 97542
|
| Hospital Charge Code |
1041810
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$76.50 |
| Rate for Payer: Aetna of IA Commercial |
$76.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.50
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.75
|
| Rate for Payer: Medical Associates Commercial |
$63.75
|
| Rate for Payer: Midlands Choice Commercial |
$59.50
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
|
|
OT Wheelchair Training Charges
|
Facility
OP
|
$85.00
|
|
|
Service Code
|
CPT 97542
|
| Hospital Charge Code |
1041810
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$42.48 |
| Max. Negotiated Rate |
$132.99 |
| Rate for Payer: Aetna of IA Commercial |
$76.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.50
|
| Rate for Payer: Aetna of IA Medicare |
$48.45
|
| Rate for Payer: Amerigroup Medicaid |
$42.90
|
| Rate for Payer: Amerigroup Medicare |
$42.92
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$42.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$42.48
|
| Rate for Payer: Medical Associates Commercial |
$63.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$42.50
|
| Rate for Payer: Midlands Choice Commercial |
$59.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$43.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$50.15
|
| Rate for Payer: Wellmark IA HMO |
$120.90
|
| Rate for Payer: Wellmark IA PPO |
$132.99
|
|
|
OT Wound Care Selective Debridement Addl Charge
|
Facility
OP
|
$85.00
|
|
|
Service Code
|
CPT 97598
|
| Hospital Charge Code |
7395136
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$42.48 |
| Max. Negotiated Rate |
$1,060.51 |
| Rate for Payer: Aetna of IA Commercial |
$76.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.50
|
| Rate for Payer: Aetna of IA Medicare |
$48.45
|
| Rate for Payer: Amerigroup Medicaid |
$42.90
|
| Rate for Payer: Amerigroup Medicare |
$42.92
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$42.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$42.48
|
| Rate for Payer: Medical Associates Commercial |
$63.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$42.50
|
| Rate for Payer: Midlands Choice Commercial |
$59.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$43.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$50.15
|
| Rate for Payer: Wellmark IA HMO |
$964.10
|
| Rate for Payer: Wellmark IA PPO |
$1,060.51
|
|
|
OT Wound Care Selective Debridement Addl Charge
|
Facility
IP
|
$85.00
|
|
|
Service Code
|
CPT 97598
|
| Hospital Charge Code |
7395136
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$76.50 |
| Rate for Payer: Aetna of IA Commercial |
$76.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.50
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.75
|
| Rate for Payer: Medical Associates Commercial |
$63.75
|
| Rate for Payer: Midlands Choice Commercial |
$59.50
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
|
|
OT Wound Care Selective Debridement Charge
|
Facility
OP
|
$85.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
7395135
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$42.48 |
| Max. Negotiated Rate |
$598.11 |
| Rate for Payer: Aetna of IA Commercial |
$76.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.50
|
| Rate for Payer: Aetna of IA Medicare |
$48.45
|
| Rate for Payer: Amerigroup Medicaid |
$42.90
|
| Rate for Payer: Amerigroup Medicare |
$42.92
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$42.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$42.48
|
| Rate for Payer: Medical Associates Commercial |
$63.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$42.50
|
| Rate for Payer: Midlands Choice Commercial |
$59.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$43.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$50.15
|
| Rate for Payer: Wellmark IA HMO |
$543.74
|
| Rate for Payer: Wellmark IA PPO |
$598.11
|
|
|
OT Wound Care Selective Debridement Charge
|
Facility
IP
|
$85.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
7395135
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$76.50 |
| Rate for Payer: Aetna of IA Commercial |
$76.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.50
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.75
|
| Rate for Payer: Medical Associates Commercial |
$63.75
|
| Rate for Payer: Midlands Choice Commercial |
$59.50
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
|
|
Outpatient Mental Health Therapy, Group - Remote
|
Facility
IP
|
$221.00
|
|
|
Service Code
|
CPT C7903
|
| Hospital Charge Code |
8945620
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$154.70 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna of IA Commercial |
$198.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$198.90
|
| Rate for Payer: Cash Price |
$176.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$165.75
|
| Rate for Payer: Medical Associates Commercial |
$165.75
|
| Rate for Payer: Midlands Choice Commercial |
$154.70
|
| Rate for Payer: United Healthcare Commercial |
$198.90
|
|
|
Outpatient Mental Health Therapy, Group - Remote
|
Facility
OP
|
$221.00
|
|
|
Service Code
|
CPT C7903
|
| Hospital Charge Code |
8945620
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$110.46 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna of IA Commercial |
$198.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$198.90
|
| Rate for Payer: Aetna of IA Medicare |
$125.97
|
| Rate for Payer: Amerigroup Medicaid |
$111.54
|
| Rate for Payer: Amerigroup Medicare |
$111.60
|
| Rate for Payer: Cash Price |
$176.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$165.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$110.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$110.46
|
| Rate for Payer: Medical Associates Commercial |
$165.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$110.50
|
| Rate for Payer: Midlands Choice Commercial |
$154.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$112.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$165.75
|
| Rate for Payer: United Healthcare Commercial |
$198.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$130.39
|
|
|
oxaliplatin 5 mg/mL 10ml SDV
|
Facility
IP
|
$104.92
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
43700366
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.44 |
| Max. Negotiated Rate |
$94.43 |
| Rate for Payer: Aetna of IA Commercial |
$94.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.43
|
| Rate for Payer: Cash Price |
$83.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.69
|
| Rate for Payer: Medical Associates Commercial |
$78.69
|
| Rate for Payer: Midlands Choice Commercial |
$73.44
|
| Rate for Payer: United Healthcare Commercial |
$94.43
|
|
|
oxaliplatin 5 mg/mL 10ml SDV
|
Facility
OP
|
$104.92
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
43700366
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.44 |
| Max. Negotiated Rate |
$94.43 |
| Rate for Payer: Aetna of IA Commercial |
$94.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.43
|
| Rate for Payer: Aetna of IA Medicare |
$59.80
|
| Rate for Payer: Amerigroup Medicaid |
$52.95
|
| Rate for Payer: Amerigroup Medicare |
$52.98
|
| Rate for Payer: Cash Price |
$83.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$52.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$52.44
|
| Rate for Payer: Medical Associates Commercial |
$78.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$52.46
|
| Rate for Payer: Midlands Choice Commercial |
$73.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$53.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$78.69
|
| Rate for Payer: United Healthcare Commercial |
$94.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.90
|
|
|
oxaliplatin 5 mg/mL 20ml
|
Facility
IP
|
$159.80
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
43700044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.86 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna of IA Commercial |
$143.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$143.82
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$119.85
|
| Rate for Payer: Medical Associates Commercial |
$119.85
|
| Rate for Payer: Midlands Choice Commercial |
$111.86
|
| Rate for Payer: United Healthcare Commercial |
$143.82
|
|
|
oxaliplatin 5 mg/mL 20ml
|
Facility
OP
|
$159.80
|
|
|
Service Code
|
CPT J9263
|
| Hospital Charge Code |
43700044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.87 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna of IA Commercial |
$143.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$143.82
|
| Rate for Payer: Aetna of IA Medicare |
$91.09
|
| Rate for Payer: Amerigroup Medicaid |
$80.65
|
| Rate for Payer: Amerigroup Medicare |
$80.70
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$119.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$79.87
|
| Rate for Payer: Medical Associates Commercial |
$119.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.90
|
| Rate for Payer: Midlands Choice Commercial |
$111.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$81.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$119.85
|
| Rate for Payer: United Healthcare Commercial |
$143.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$94.28
|
|
|
oxazepam 15 mg Cap
|
Facility
IP
|
$6.29
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$5.66 |
| Rate for Payer: Aetna of IA Commercial |
$5.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.66
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.72
|
| Rate for Payer: Medical Associates Commercial |
$4.72
|
| Rate for Payer: Midlands Choice Commercial |
$4.40
|
| Rate for Payer: United Healthcare Commercial |
$5.66
|
|
|
oxazepam 15 mg Cap
|
Facility
OP
|
$6.29
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$5.66 |
| Rate for Payer: Aetna of IA Commercial |
$5.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.66
|
| Rate for Payer: Aetna of IA Medicare |
$3.59
|
| Rate for Payer: Amerigroup Medicaid |
$3.17
|
| Rate for Payer: Amerigroup Medicare |
$3.18
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.14
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.14
|
| Rate for Payer: Medical Associates Commercial |
$4.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.14
|
| Rate for Payer: Midlands Choice Commercial |
$4.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.72
|
| Rate for Payer: United Healthcare Commercial |
$5.66
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.71
|
|
|
oxcarbazepine 600mg Tab
|
Facility
IP
|
$2.08
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43721811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna of IA Commercial |
$1.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.87
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.56
|
| Rate for Payer: Medical Associates Commercial |
$1.56
|
| Rate for Payer: Midlands Choice Commercial |
$1.46
|
| Rate for Payer: United Healthcare Commercial |
$1.87
|
|
|
oxcarbazepine 600mg Tab
|
Facility
OP
|
$2.08
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43721811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna of IA Commercial |
$1.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.87
|
| Rate for Payer: Aetna of IA Medicare |
$1.19
|
| Rate for Payer: Amerigroup Medicaid |
$1.05
|
| Rate for Payer: Amerigroup Medicare |
$1.05
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.56
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.04
|
| Rate for Payer: Medical Associates Commercial |
$1.56
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.04
|
| Rate for Payer: Midlands Choice Commercial |
$1.46
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$1.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.23
|
|
|
Oxcarbazepine Trileptal DMCL
|
Facility
IP
|
$131.00
|
|
|
Service Code
|
CPT 80183
|
| Hospital Charge Code |
8037746
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$117.90 |
| Rate for Payer: Aetna of IA Commercial |
$117.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.90
|
| Rate for Payer: Cash Price |
$104.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$98.25
|
| Rate for Payer: Medical Associates Commercial |
$98.25
|
| Rate for Payer: Midlands Choice Commercial |
$91.70
|
| Rate for Payer: United Healthcare Commercial |
$117.90
|
|
