|
OHPS Psychotherapy - Individual 38-57 min
|
Facility
|
OP
|
$363.00
|
|
|
Service Code
|
CPT 90834
|
| Hospital Charge Code |
8987986
|
|
Hospital Revenue Code
|
914
|
| Min. Negotiated Rate |
$163.35 |
| Max. Negotiated Rate |
$326.70 |
| Rate for Payer: Aetna of IA Commercial |
$326.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$326.70
|
| Rate for Payer: Aetna of IA Medicare |
$206.91
|
| Rate for Payer: Amerigroup Medicaid |
$209.38
|
| Rate for Payer: Amerigroup Medicare |
$164.98
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$272.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$163.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$207.35
|
| Rate for Payer: Medical Associates Commercial |
$272.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$163.35
|
| Rate for Payer: Midlands Choice Commercial |
$254.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$210.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$187.85
|
| Rate for Payer: United Healthcare Commercial |
$326.70
|
| Rate for Payer: Wellmark IA HMO WHPI |
$247.44
|
| Rate for Payer: Wellmark IA PPO |
$272.57
|
|
|
OHPS Psychotherapy - Individual 38-57 min
|
Facility
|
IP
|
$363.00
|
|
|
Service Code
|
CPT 90834
|
| Hospital Charge Code |
8987986
|
|
Hospital Revenue Code
|
914
|
| Min. Negotiated Rate |
$254.10 |
| Max. Negotiated Rate |
$326.70 |
| Rate for Payer: Aetna of IA Commercial |
$326.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$326.70
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$272.25
|
| Rate for Payer: Medical Associates Commercial |
$272.25
|
| Rate for Payer: Midlands Choice Commercial |
$254.10
|
| Rate for Payer: United Healthcare Commercial |
$326.70
|
|
|
OHPS Psychotherapy - Individual 58 min or more
|
Facility
|
IP
|
$363.00
|
|
|
Service Code
|
CPT 90837
|
| Hospital Charge Code |
8987987
|
|
Hospital Revenue Code
|
914
|
| Min. Negotiated Rate |
$254.10 |
| Max. Negotiated Rate |
$326.70 |
| Rate for Payer: Aetna of IA Commercial |
$326.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$326.70
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$272.25
|
| Rate for Payer: Medical Associates Commercial |
$272.25
|
| Rate for Payer: Midlands Choice Commercial |
$254.10
|
| Rate for Payer: United Healthcare Commercial |
$326.70
|
|
|
OHPS Psychotherapy - Individual 58 min or more
|
Facility
|
OP
|
$363.00
|
|
|
Service Code
|
CPT 90837
|
| Hospital Charge Code |
8987987
|
|
Hospital Revenue Code
|
914
|
| Min. Negotiated Rate |
$163.35 |
| Max. Negotiated Rate |
$326.70 |
| Rate for Payer: Aetna of IA Commercial |
$326.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$326.70
|
| Rate for Payer: Aetna of IA Medicare |
$206.91
|
| Rate for Payer: Amerigroup Medicaid |
$209.38
|
| Rate for Payer: Amerigroup Medicare |
$164.98
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Cash Price |
$290.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$272.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$163.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$207.35
|
| Rate for Payer: Medical Associates Commercial |
$272.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$163.35
|
| Rate for Payer: Midlands Choice Commercial |
$254.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$210.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$187.85
|
| Rate for Payer: United Healthcare Commercial |
$326.70
|
| Rate for Payer: Wellmark IA HMO WHPI |
$247.44
|
| Rate for Payer: Wellmark IA PPO |
$272.57
|
|
|
OLANZapine 5 mg Tab [VDMC]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Aetna of IA Medicare |
$1.20
|
| Rate for Payer: Amerigroup Medicaid |
$1.22
|
| Rate for Payer: Amerigroup Medicare |
$0.96
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.20
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.95
|
| Rate for Payer: Midlands Choice Commercial |
$1.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.24
|
|
|
OLANZapine 5 mg Tab [VDMC]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Midlands Choice Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
|
|
OLIGOCLONAL BANDING
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
8093941
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of IA Commercial |
$147.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$147.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$123.00
|
| Rate for Payer: Medical Associates Commercial |
$123.00
|
| Rate for Payer: Midlands Choice Commercial |
$114.80
|
| Rate for Payer: United Healthcare Commercial |
$147.60
|
|
|
OLIGOCLONAL BANDING
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
8093941
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$73.80 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of IA Commercial |
$147.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$147.60
|
| Rate for Payer: Aetna of IA Medicare |
$93.48
|
| Rate for Payer: Amerigroup Medicaid |
$94.60
|
| Rate for Payer: Amerigroup Medicare |
$74.54
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$123.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$93.68
|
| Rate for Payer: Medical Associates Commercial |
$123.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.80
|
| Rate for Payer: Midlands Choice Commercial |
$114.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$95.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$84.87
|
| Rate for Payer: United Healthcare Commercial |
$147.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$96.76
|
| Rate for Payer: Wellmark IA HMO WHPI |
$121.95
|
| Rate for Payer: Wellmark IA PPO |
$134.33
|
|
|
Oligoclonal Band Profile DMCL
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
8037734
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of IA Commercial |
$147.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$147.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$123.00
|
| Rate for Payer: Medical Associates Commercial |
$123.00
|
| Rate for Payer: Midlands Choice Commercial |
$114.80
|
| Rate for Payer: United Healthcare Commercial |
$147.60
|
|
|
Oligoclonal Band Profile DMCL
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
8037734
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$73.80 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of IA Commercial |
$147.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$147.60
|
| Rate for Payer: Aetna of IA Medicare |
$93.48
|
| Rate for Payer: Amerigroup Medicaid |
$94.60
|
| Rate for Payer: Amerigroup Medicare |
$74.54
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$123.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$93.68
|
| Rate for Payer: Medical Associates Commercial |
$123.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.80
|
| Rate for Payer: Midlands Choice Commercial |
$114.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$95.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$84.87
|
| Rate for Payer: United Healthcare Commercial |
$147.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$96.76
|
| Rate for Payer: Wellmark IA HMO WHPI |
$121.95
|
| Rate for Payer: Wellmark IA PPO |
$134.33
|
|
|
OLIVE WIRE 0.062
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8759904
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$24.30 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of IA Commercial |
$48.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.60
|
| Rate for Payer: Aetna of IA Medicare |
$30.78
|
| Rate for Payer: Amerigroup Medicaid |
$31.15
|
| Rate for Payer: Amerigroup Medicare |
$24.54
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.84
|
| Rate for Payer: Medical Associates Commercial |
$40.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.30
|
| Rate for Payer: Midlands Choice Commercial |
$37.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$27.94
|
| Rate for Payer: United Healthcare Commercial |
$48.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.86
|
|
|
OLIVE WIRE 0.062
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8759904
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of IA Commercial |
$48.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.60
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.50
|
| Rate for Payer: Medical Associates Commercial |
$40.50
|
| Rate for Payer: Midlands Choice Commercial |
$37.80
|
| Rate for Payer: United Healthcare Commercial |
$48.60
|
|
|
OLIVE WIRE 1.4MM
|
Facility
|
IP
|
$172.00
|
|
| Hospital Charge Code |
8047370
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of IA Commercial |
$154.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$154.80
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$129.00
|
| Rate for Payer: Medical Associates Commercial |
$129.00
|
| Rate for Payer: Midlands Choice Commercial |
$120.40
|
| Rate for Payer: United Healthcare Commercial |
$154.80
|
|
|
OLIVE WIRE 1.4MM
|
Facility
|
OP
|
$172.00
|
|
| Hospital Charge Code |
8047370
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$77.40 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of IA Commercial |
$154.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$154.80
|
| Rate for Payer: Aetna of IA Medicare |
$98.04
|
| Rate for Payer: Amerigroup Medicaid |
$99.21
|
| Rate for Payer: Amerigroup Medicare |
$78.17
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$129.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$77.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$98.25
|
| Rate for Payer: Medical Associates Commercial |
$129.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$77.40
|
| Rate for Payer: Midlands Choice Commercial |
$120.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$99.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.01
|
| Rate for Payer: United Healthcare Commercial |
$154.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$101.48
|
|
|
olmesartan 20 mg Tab [VDMC]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410207
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of IA Commercial |
$1.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.16
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.74
|
| Rate for Payer: Medical Associates Commercial |
$0.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.67
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.76
|
|
|
olmesartan 20 mg Tab [VDMC]
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410207
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of IA Commercial |
$1.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.16
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.97
|
| Rate for Payer: Medical Associates Commercial |
$0.97
|
| Rate for Payer: Midlands Choice Commercial |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
|
|
omalizumab 150 mg/mL syringe SDS [VDMC]
|
Facility
|
IP
|
$2,932.24
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
18591016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,052.57 |
| Max. Negotiated Rate |
$2,639.02 |
| Rate for Payer: Aetna of IA Commercial |
$2,639.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,639.02
|
| Rate for Payer: Cash Price |
$2,345.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,199.18
|
| Rate for Payer: Medical Associates Commercial |
$2,199.18
|
| Rate for Payer: Midlands Choice Commercial |
$2,052.57
|
| Rate for Payer: United Healthcare Commercial |
$2,639.02
|
|
|
omalizumab 150 mg/mL syringe SDS [VDMC]
|
Facility
|
OP
|
$2,932.24
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
18591016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,319.51 |
| Max. Negotiated Rate |
$2,639.02 |
| Rate for Payer: Aetna of IA Commercial |
$2,639.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,639.02
|
| Rate for Payer: Aetna of IA Medicare |
$1,671.38
|
| Rate for Payer: Amerigroup Medicaid |
$1,691.32
|
| Rate for Payer: Amerigroup Medicare |
$1,332.70
|
| Rate for Payer: Cash Price |
$2,345.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,199.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,319.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,674.90
|
| Rate for Payer: Medical Associates Commercial |
$2,199.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,319.51
|
| Rate for Payer: Midlands Choice Commercial |
$2,052.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,699.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,517.43
|
| Rate for Payer: United Healthcare Commercial |
$2,639.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,730.02
|
|
|
omalizumab 300 mg/2 mL syringe SDS [VDMC]
|
Facility
|
OP
|
$5,764.48
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
28363553
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,594.02 |
| Max. Negotiated Rate |
$5,188.03 |
| Rate for Payer: Aetna of IA Commercial |
$5,188.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,188.03
|
| Rate for Payer: Aetna of IA Medicare |
$3,285.75
|
| Rate for Payer: Amerigroup Medicaid |
$3,324.95
|
| Rate for Payer: Amerigroup Medicare |
$2,619.96
|
| Rate for Payer: Cash Price |
$4,611.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,323.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,594.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,292.67
|
| Rate for Payer: Medical Associates Commercial |
$4,323.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,594.02
|
| Rate for Payer: Midlands Choice Commercial |
$4,035.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,341.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,983.12
|
| Rate for Payer: United Healthcare Commercial |
$5,188.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,401.04
|
|
|
omalizumab 300 mg/2 mL syringe SDS [VDMC]
|
Facility
|
IP
|
$5,764.48
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
28363553
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,035.14 |
| Max. Negotiated Rate |
$5,188.03 |
| Rate for Payer: Aetna of IA Commercial |
$5,188.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,188.03
|
| Rate for Payer: Cash Price |
$4,611.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,323.36
|
| Rate for Payer: Medical Associates Commercial |
$4,323.36
|
| Rate for Payer: Midlands Choice Commercial |
$4,035.14
|
| Rate for Payer: United Healthcare Commercial |
$5,188.03
|
|
|
omalizumab 75 mg/0.5 mL syringe SDS [VDMC]
|
Facility
|
IP
|
$1,484.96
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
26003865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,039.47 |
| Max. Negotiated Rate |
$1,336.46 |
| Rate for Payer: Aetna of IA Commercial |
$1,336.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,336.46
|
| Rate for Payer: Cash Price |
$1,187.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,113.72
|
| Rate for Payer: Medical Associates Commercial |
$1,113.72
|
| Rate for Payer: Midlands Choice Commercial |
$1,039.47
|
| Rate for Payer: United Healthcare Commercial |
$1,336.46
|
|
|
omalizumab 75 mg/0.5 mL syringe SDS [VDMC]
|
Facility
|
OP
|
$1,484.96
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
26003865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$668.23 |
| Max. Negotiated Rate |
$1,336.46 |
| Rate for Payer: Aetna of IA Commercial |
$1,336.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,336.46
|
| Rate for Payer: Aetna of IA Medicare |
$846.43
|
| Rate for Payer: Amerigroup Medicaid |
$856.52
|
| Rate for Payer: Amerigroup Medicare |
$674.91
|
| Rate for Payer: Cash Price |
$1,187.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,113.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$668.23
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$848.21
|
| Rate for Payer: Medical Associates Commercial |
$1,113.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$668.23
|
| Rate for Payer: Midlands Choice Commercial |
$1,039.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$860.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$768.47
|
| Rate for Payer: United Healthcare Commercial |
$1,336.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$876.13
|
|
|
omega-3 polyunsaturated fatty acids ethyl esters 1000 mg oral capsule [VDMC]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of IA Commercial |
$1.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.48
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.23
|
| Rate for Payer: Medical Associates Commercial |
$1.23
|
| Rate for Payer: Midlands Choice Commercial |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
|
|
omega-3 polyunsaturated fatty acids ethyl esters 1000 mg oral capsule [VDMC]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of IA Commercial |
$1.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.48
|
| Rate for Payer: Aetna of IA Medicare |
$0.94
|
| Rate for Payer: Amerigroup Medicaid |
$0.95
|
| Rate for Payer: Amerigroup Medicare |
$0.75
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.23
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.94
|
| Rate for Payer: Medical Associates Commercial |
$1.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.74
|
| Rate for Payer: Midlands Choice Commercial |
$1.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.97
|
|
|
OMEGA 4.75MM PEEK KNOTLESS ANCHOR SYSTEM
|
Facility
|
OP
|
$765.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8771316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$344.25 |
| Max. Negotiated Rate |
$688.50 |
| Rate for Payer: Aetna of IA Commercial |
$688.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$688.50
|
| Rate for Payer: Aetna of IA Medicare |
$436.05
|
| Rate for Payer: Amerigroup Medicaid |
$441.25
|
| Rate for Payer: Amerigroup Medicare |
$347.69
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$573.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$344.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$436.97
|
| Rate for Payer: Medical Associates Commercial |
$573.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$344.25
|
| Rate for Payer: Midlands Choice Commercial |
$535.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$443.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$395.89
|
| Rate for Payer: United Healthcare Commercial |
$688.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$451.35
|
|
