|
PROTEIN S ACTIVITY
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 85305
|
| Hospital Charge Code |
8093943
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Wellmark IA HMO |
$24.18
|
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$73.69
|
| Rate for Payer: Amerigroup Medicare |
$73.73
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.97
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.00
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.10
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$74.05
|
| Rate for Payer: Oscar Health of IA Commercial |
$109.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.50
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
| Rate for Payer: Wellmark IA PPO |
$26.60
|
|
|
PROTEIN S ACTIVITY
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 85305
|
| Hospital Charge Code |
8093943
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
Protein S Activity DMCL
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 85305
|
| Hospital Charge Code |
8037788
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
Protein S Activity DMCL
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 85305
|
| Hospital Charge Code |
8037788
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$73.69
|
| Rate for Payer: Amerigroup Medicare |
$73.73
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.97
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.00
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.10
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$74.05
|
| Rate for Payer: Oscar Health of IA Commercial |
$109.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.50
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
| Rate for Payer: Wellmark IA HMO |
$24.18
|
| Rate for Payer: Wellmark IA PPO |
$26.60
|
|
|
Protein S Free Antigen with Reflex DMCL
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 85306
|
| Hospital Charge Code |
8037789
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
Protein S Free Antigen with Reflex DMCL
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 85306
|
| Hospital Charge Code |
8037789
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$73.69
|
| Rate for Payer: Amerigroup Medicare |
$73.73
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.97
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.00
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.10
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$74.05
|
| Rate for Payer: Oscar Health of IA Commercial |
$109.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.50
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
| Rate for Payer: Wellmark IA HMO |
$24.18
|
| Rate for Payer: Wellmark IA PPO |
$26.60
|
|
|
Protein Total DMCL
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 84155
|
| Hospital Charge Code |
8037790
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
|
|
Protein Total DMCL
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 84155
|
| Hospital Charge Code |
8037790
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Aetna of IA Medicare |
$22.80
|
| Rate for Payer: Amerigroup Medicaid |
$20.19
|
| Rate for Payer: Amerigroup Medicare |
$20.20
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.99
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.30
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$20.29
|
| Rate for Payer: Oscar Health of IA Commercial |
$30.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
Protein Urine Random DMCL
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
8037738
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Aetna of IA Medicare |
$34.77
|
| Rate for Payer: Amerigroup Medicaid |
$30.79
|
| Rate for Payer: Amerigroup Medicare |
$30.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.49
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.50
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.96
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$30.94
|
| Rate for Payer: Oscar Health of IA Commercial |
$45.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.75
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.99
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
Protein Urine Random DMCL
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
8037738
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
|
|
Protein Urine Timed DMCL
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
8037739
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
|
|
Protein Urine Timed DMCL
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
8037739
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Aetna of IA Medicare |
$34.77
|
| Rate for Payer: Amerigroup Medicaid |
$30.79
|
| Rate for Payer: Amerigroup Medicare |
$30.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.49
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.50
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.96
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$30.94
|
| Rate for Payer: Oscar Health of IA Commercial |
$45.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.75
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.99
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
prucalopride 2 mg Tab [VDMC]
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
26827722
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna of IA Commercial |
$56.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.70
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.25
|
| Rate for Payer: Medical Associates Commercial |
$47.25
|
| Rate for Payer: Midlands Choice Commercial |
$44.10
|
| Rate for Payer: United Healthcare Commercial |
$56.70
|
|
|
prucalopride 2 mg Tab [VDMC]
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
26827722
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.49 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna of IA Commercial |
$56.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.70
|
| Rate for Payer: Aetna of IA Medicare |
$35.91
|
| Rate for Payer: Amerigroup Medicaid |
$31.80
|
| Rate for Payer: Amerigroup Medicare |
$31.82
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.49
|
| Rate for Payer: Medical Associates Commercial |
$47.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.50
|
| Rate for Payer: Midlands Choice Commercial |
$44.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.97
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$31.95
|
| Rate for Payer: Oscar Health of IA Commercial |
$47.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.25
|
| Rate for Payer: United Healthcare Commercial |
$56.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.17
|
|
|
PSA DIAG
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
1634882
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
|
|
PSA DIAG
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
8037784
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
|
|
PSA DIAG
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
8037784
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Aetna of IA Medicare |
$85.50
|
| Rate for Payer: Amerigroup Medicaid |
$75.70
|
| Rate for Payer: Amerigroup Medicare |
$75.75
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.97
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.00
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.12
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$76.08
|
| Rate for Payer: Oscar Health of IA Commercial |
$112.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.50
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$88.50
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
PSA DIAG
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
CPT 84153
|
| Hospital Charge Code |
1634882
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Aetna of IA Medicare |
$84.36
|
| Rate for Payer: Amerigroup Medicaid |
$74.70
|
| Rate for Payer: Amerigroup Medicare |
$74.74
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$74.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.97
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$74.00
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$75.11
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$75.07
|
| Rate for Payer: Oscar Health of IA Commercial |
$111.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$111.00
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$87.32
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
PSA FREE
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
8038996
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
|
|
PSA FREE
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 84154
|
| Hospital Charge Code |
8038996
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Aetna of IA Medicare |
$85.50
|
| Rate for Payer: Amerigroup Medicaid |
$75.70
|
| Rate for Payer: Amerigroup Medicare |
$75.75
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.97
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.00
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.12
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$76.08
|
| Rate for Payer: Oscar Health of IA Commercial |
$112.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.50
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$88.50
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
pseudoephedrine 120 mg ER Tab [VDMC]
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Aetna of IA Commercial |
$2.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.09
|
| Rate for Payer: Aetna of IA Medicare |
$1.32
|
| Rate for Payer: Amerigroup Medicaid |
$1.17
|
| Rate for Payer: Amerigroup Medicare |
$1.17
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.74
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.16
|
| Rate for Payer: Medical Associates Commercial |
$1.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.16
|
| Rate for Payer: Midlands Choice Commercial |
$1.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.18
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.18
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$2.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.37
|
|
|
pseudoephedrine 120 mg ER Tab [VDMC]
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417490
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Aetna of IA Commercial |
$2.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.09
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.74
|
| Rate for Payer: Medical Associates Commercial |
$1.74
|
| Rate for Payer: Midlands Choice Commercial |
$1.62
|
| Rate for Payer: United Healthcare Commercial |
$2.09
|
|
|
pseudoephedrine 15mg/5ml LIQD [VDMC]
|
Facility
|
OP
|
$7.04
|
|
|
Service Code
|
NDC 54838-0104-40
|
| Hospital Charge Code |
10430251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$6.34 |
| Rate for Payer: Aetna of IA Commercial |
$6.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.34
|
| Rate for Payer: Aetna of IA Medicare |
$4.01
|
| Rate for Payer: Amerigroup Medicaid |
$3.55
|
| Rate for Payer: Amerigroup Medicare |
$3.56
|
| Rate for Payer: Cash Price |
$5.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.52
|
| Rate for Payer: Medical Associates Commercial |
$5.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.52
|
| Rate for Payer: Midlands Choice Commercial |
$4.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.57
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$3.57
|
| Rate for Payer: Oscar Health of IA Commercial |
$5.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.28
|
| Rate for Payer: United Healthcare Commercial |
$6.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.15
|
|
|
pseudoephedrine 15mg/5ml LIQD [VDMC]
|
Facility
|
IP
|
$7.04
|
|
|
Service Code
|
NDC 54838-0104-40
|
| Hospital Charge Code |
10430251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$6.34 |
| Rate for Payer: Aetna of IA Commercial |
$6.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.34
|
| Rate for Payer: Cash Price |
$5.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.28
|
| Rate for Payer: Medical Associates Commercial |
$5.28
|
| Rate for Payer: Midlands Choice Commercial |
$4.93
|
| Rate for Payer: United Healthcare Commercial |
$6.34
|
|
|
pseudoephedrine 30 mg Tab [VDMC]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417559
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of IA Commercial |
$0.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.97
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.81
|
| Rate for Payer: Medical Associates Commercial |
$0.81
|
| Rate for Payer: Midlands Choice Commercial |
$0.76
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
|
