|
nystatin Top 100,000 units/g Pwdr 15 gm [VDMC]
|
Facility
|
OP
|
$36.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10409744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.49 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: Aetna of IA Commercial |
$32.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.98
|
| Rate for Payer: Aetna of IA Medicare |
$20.88
|
| Rate for Payer: Amerigroup Medicaid |
$21.13
|
| Rate for Payer: Amerigroup Medicare |
$16.65
|
| Rate for Payer: Cash Price |
$29.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$27.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$16.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.93
|
| Rate for Payer: Medical Associates Commercial |
$27.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.49
|
| Rate for Payer: Midlands Choice Commercial |
$25.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.96
|
| Rate for Payer: United Healthcare Commercial |
$32.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$21.62
|
|
|
OBSERVATION OR INPT MODERATE COMPLEXITY
|
Facility
|
IP
|
$278.00
|
|
|
Service Code
|
CPT 99235
|
| Hospital Charge Code |
5140783
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$194.60 |
| Max. Negotiated Rate |
$250.20 |
| Rate for Payer: Aetna of IA Commercial |
$250.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$250.20
|
| Rate for Payer: Cash Price |
$222.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$208.50
|
| Rate for Payer: Medical Associates Commercial |
$208.50
|
| Rate for Payer: Midlands Choice Commercial |
$194.60
|
| Rate for Payer: United Healthcare Commercial |
$250.20
|
|
|
OBSERVATION OR INPT MODERATE COMPLEXITY
|
Facility
|
OP
|
$278.00
|
|
|
Service Code
|
CPT 99235
|
| Hospital Charge Code |
5140783
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$125.10 |
| Max. Negotiated Rate |
$250.20 |
| Rate for Payer: Aetna of IA Commercial |
$250.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$250.20
|
| Rate for Payer: Aetna of IA Medicare |
$158.46
|
| Rate for Payer: Amerigroup Medicaid |
$160.35
|
| Rate for Payer: Amerigroup Medicare |
$126.35
|
| Rate for Payer: Cash Price |
$222.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$208.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$125.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$158.79
|
| Rate for Payer: Medical Associates Commercial |
$208.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$125.10
|
| Rate for Payer: Midlands Choice Commercial |
$194.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$161.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$143.86
|
| Rate for Payer: United Healthcare Commercial |
$250.20
|
|
|
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
|
|
|
Occ Health Pre Work Screen
|
Facility
|
OP
|
$75.00
|
|
| Hospital Charge Code |
8782365
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$33.75 |
| 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 |
$43.26
|
| Rate for Payer: Amerigroup Medicare |
$34.09
|
| 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 |
$33.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$42.84
|
| Rate for Payer: Medical Associates Commercial |
$56.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.75
|
| Rate for Payer: Midlands Choice Commercial |
$52.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$43.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$38.81
|
| Rate for Payer: United Healthcare Commercial |
$67.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$44.25
|
|
|
OCCULT BLOOD OTHER
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
CPT 82271
|
| Hospital Charge Code |
4022862
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.45 |
| 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 |
$23.65
|
| Rate for Payer: Amerigroup Medicare |
$18.63
|
| 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 |
$18.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.42
|
| Rate for Payer: Medical Associates Commercial |
$30.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.45
|
| Rate for Payer: Midlands Choice Commercial |
$28.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.22
|
| Rate for Payer: United Healthcare Commercial |
$36.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.19
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
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-STOOL
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 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
|
|
|
OCCULT-BLOOD-STOOL
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS G0328
|
| Hospital Charge Code |
4022859
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.25 |
| 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 |
$37.49
|
| Rate for Payer: Amerigroup Medicare |
$29.54
|
| 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 |
$29.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.13
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.25
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.64
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.35
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
octreotide 100 mcg/mL Sol [VDMC]
|
Facility
|
OP
|
$26.07
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
23341694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.73 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$23.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.46
|
| Rate for Payer: Aetna of IA Medicare |
$14.86
|
| Rate for Payer: Amerigroup Medicaid |
$15.04
|
| Rate for Payer: Amerigroup Medicare |
$11.85
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.55
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.89
|
| Rate for Payer: Medical Associates Commercial |
$19.55
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.73
|
| Rate for Payer: Midlands Choice Commercial |
$18.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.49
|
| Rate for Payer: United Healthcare Commercial |
$23.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.38
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
octreotide 100 mcg/mL Sol [VDMC]
|
Facility
|
IP
|
$26.07
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
23341694
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Aetna of IA Commercial |
$23.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.46
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.55
|
| Rate for Payer: Medical Associates Commercial |
$19.55
|
| Rate for Payer: Midlands Choice Commercial |
$18.25
|
| Rate for Payer: United Healthcare Commercial |
$23.46
|
|
|
Ocular lubricant preserved drops Sol 15ml [VDMC]
|
Facility
|
OP
|
$22.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
22702443
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$20.12 |
| Rate for Payer: Aetna of IA Commercial |
$20.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.12
|
| Rate for Payer: Aetna of IA Medicare |
$12.75
|
| Rate for Payer: Amerigroup Medicaid |
$12.90
|
| Rate for Payer: Amerigroup Medicare |
$10.16
|
| Rate for Payer: Cash Price |
$17.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.77
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.77
|
| Rate for Payer: Medical Associates Commercial |
$16.77
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.06
|
| Rate for Payer: Midlands Choice Commercial |
$15.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.57
|
| Rate for Payer: United Healthcare Commercial |
$20.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.19
|
|
|
Ocular lubricant preserved drops Sol 15ml [VDMC]
|
Facility
|
IP
|
$22.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
22702443
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$20.12 |
| Rate for Payer: Aetna of IA Commercial |
$20.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.12
|
| Rate for Payer: Cash Price |
$17.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.77
|
| Rate for Payer: Medical Associates Commercial |
$16.77
|
| Rate for Payer: Midlands Choice Commercial |
$15.65
|
| Rate for Payer: United Healthcare Commercial |
$20.12
|
|
|
ofloxacin ophthalmic 0.3% 5ml drops [VDMC]
|
Facility
|
OP
|
$59.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11338413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.69 |
| Max. Negotiated Rate |
$53.39 |
| Rate for Payer: Aetna of IA Commercial |
$53.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$53.39
|
| Rate for Payer: Aetna of IA Medicare |
$33.81
|
| Rate for Payer: Amerigroup Medicaid |
$34.22
|
| Rate for Payer: Amerigroup Medicare |
$26.96
|
| Rate for Payer: Cash Price |
$47.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$44.49
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.69
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.88
|
| Rate for Payer: Medical Associates Commercial |
$44.49
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.69
|
| Rate for Payer: Midlands Choice Commercial |
$41.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$34.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.70
|
| Rate for Payer: United Healthcare Commercial |
$53.39
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.00
|
|
|
ofloxacin ophthalmic 0.3% 5ml drops [VDMC]
|
Facility
|
IP
|
$59.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11338413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.52 |
| Max. Negotiated Rate |
$53.39 |
| Rate for Payer: Aetna of IA Commercial |
$53.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$53.39
|
| Rate for Payer: Cash Price |
$47.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$44.49
|
| Rate for Payer: Medical Associates Commercial |
$44.49
|
| Rate for Payer: Midlands Choice Commercial |
$41.52
|
| Rate for Payer: United Healthcare Commercial |
$53.39
|
|
|
ofloxacin Otic 0.3% 5ml drops [VDMC]
|
Facility
|
OP
|
$254.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$114.37 |
| Max. Negotiated Rate |
$228.74 |
| Rate for Payer: Aetna of IA Commercial |
$228.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$228.74
|
| Rate for Payer: Aetna of IA Medicare |
$144.87
|
| Rate for Payer: Amerigroup Medicaid |
$146.60
|
| Rate for Payer: Amerigroup Medicare |
$115.52
|
| Rate for Payer: Cash Price |
$203.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$190.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$114.37
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$145.18
|
| Rate for Payer: Medical Associates Commercial |
$190.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$114.37
|
| Rate for Payer: Midlands Choice Commercial |
$177.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$147.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$131.53
|
| Rate for Payer: United Healthcare Commercial |
$228.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$149.95
|
|
|
ofloxacin Otic 0.3% 5ml drops [VDMC]
|
Facility
|
IP
|
$254.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$177.91 |
| Max. Negotiated Rate |
$228.74 |
| Rate for Payer: Aetna of IA Commercial |
$228.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$228.74
|
| Rate for Payer: Cash Price |
$203.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$190.62
|
| Rate for Payer: Medical Associates Commercial |
$190.62
|
| Rate for Payer: Midlands Choice Commercial |
$177.91
|
| Rate for Payer: United Healthcare Commercial |
$228.74
|
|
|
OHPS Group Psychotherapy
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
CPT 90853
|
| Hospital Charge Code |
8987990
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$99.45 |
| 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 |
$127.47
|
| Rate for Payer: Amerigroup Medicare |
$100.44
|
| Rate for Payer: Cash Price |
$176.80
|
| 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 |
$99.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$126.24
|
| Rate for Payer: Medical Associates Commercial |
$165.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$99.45
|
| Rate for Payer: Midlands Choice Commercial |
$154.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$128.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$114.37
|
| Rate for Payer: United Healthcare Commercial |
$198.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$148.18
|
| Rate for Payer: Wellmark IA PPO |
$163.23
|
|
|
OHPS Group Psychotherapy
|
Facility
|
IP
|
$221.00
|
|
|
Service Code
|
CPT 90853
|
| Hospital Charge Code |
8987990
|
|
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
|
|
|
OHPS Psychotherapy - Family w/o Patient
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT 90846
|
| Hospital Charge Code |
8987988
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of IA Commercial |
$159.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$159.30
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.75
|
| Rate for Payer: Medical Associates Commercial |
$132.75
|
| Rate for Payer: Midlands Choice Commercial |
$123.90
|
| Rate for Payer: United Healthcare Commercial |
$159.30
|
|
|
OHPS Psychotherapy - Family w/o Patient
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT 90846
|
| Hospital Charge Code |
8987988
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$79.65 |
| Max. Negotiated Rate |
$272.57 |
| Rate for Payer: Aetna of IA Commercial |
$159.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$159.30
|
| Rate for Payer: Aetna of IA Medicare |
$100.89
|
| Rate for Payer: Amerigroup Medicaid |
$102.09
|
| Rate for Payer: Amerigroup Medicare |
$80.45
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$101.10
|
| Rate for Payer: Medical Associates Commercial |
$132.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.65
|
| Rate for Payer: Midlands Choice Commercial |
$123.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.60
|
| Rate for Payer: United Healthcare Commercial |
$159.30
|
| Rate for Payer: Wellmark IA HMO WHPI |
$247.44
|
| Rate for Payer: Wellmark IA PPO |
$272.57
|
|
|
OHPS Psychotherapy - Family w/ Patient
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT 90847
|
| Hospital Charge Code |
8987989
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of IA Commercial |
$159.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$159.30
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.75
|
| Rate for Payer: Medical Associates Commercial |
$132.75
|
| Rate for Payer: Midlands Choice Commercial |
$123.90
|
| Rate for Payer: United Healthcare Commercial |
$159.30
|
|
|
OHPS Psychotherapy - Family w/ Patient
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT 90847
|
| Hospital Charge Code |
8987989
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$79.65 |
| Max. Negotiated Rate |
$272.57 |
| Rate for Payer: Aetna of IA Commercial |
$159.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$159.30
|
| Rate for Payer: Aetna of IA Medicare |
$100.89
|
| Rate for Payer: Amerigroup Medicaid |
$102.09
|
| Rate for Payer: Amerigroup Medicare |
$80.45
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$101.10
|
| Rate for Payer: Medical Associates Commercial |
$132.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.65
|
| Rate for Payer: Midlands Choice Commercial |
$123.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.60
|
| Rate for Payer: United Healthcare Commercial |
$159.30
|
| Rate for Payer: Wellmark IA HMO WHPI |
$247.44
|
| Rate for Payer: Wellmark IA PPO |
$272.57
|
|
|
OHPS Psychotherapy - Individual 16-37 min
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
CPT 90832
|
| Hospital Charge Code |
8987985
|
|
Hospital Revenue Code
|
914
|
| Min. Negotiated Rate |
$81.45 |
| 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 |
$104.40
|
| Rate for Payer: Amerigroup Medicare |
$82.26
|
| Rate for Payer: Cash Price |
$144.80
|
| 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 |
$81.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$103.39
|
| Rate for Payer: Medical Associates Commercial |
$135.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.45
|
| Rate for Payer: Midlands Choice Commercial |
$126.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.67
|
| Rate for Payer: United Healthcare Commercial |
$162.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$107.77
|
| Rate for Payer: Wellmark IA PPO |
$118.71
|
|
|
OHPS Psychotherapy - Individual 16-37 min
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
CPT 90832
|
| Hospital Charge Code |
8987985
|
|
Hospital Revenue Code
|
914
|
| 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
|
|
