|
pyridoxine 50 mg Tab
|
Facility
IP
|
$1.05
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706037
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of IA Commercial |
$0.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.95
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.79
|
| Rate for Payer: Medical Associates Commercial |
$0.79
|
| Rate for Payer: Midlands Choice Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
Quantiferon TB Gold Plus DMCL
|
Facility
IP
|
$140.00
|
|
|
Service Code
|
CPT 86480
|
| Hospital Charge Code |
8488909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna of IA Commercial |
$126.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.00
|
| Rate for Payer: Medical Associates Commercial |
$105.00
|
| Rate for Payer: Midlands Choice Commercial |
$98.00
|
| Rate for Payer: United Healthcare Commercial |
$126.00
|
|
|
Quantiferon TB Gold Plus DMCL
|
Facility
OP
|
$140.00
|
|
|
Service Code
|
CPT 86480
|
| Hospital Charge Code |
8488909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.97 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna of IA Commercial |
$126.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.00
|
| Rate for Payer: Aetna of IA Medicare |
$79.80
|
| Rate for Payer: Amerigroup Medicaid |
$70.66
|
| Rate for Payer: Amerigroup Medicare |
$70.70
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$70.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.97
|
| Rate for Payer: Medical Associates Commercial |
$105.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$70.00
|
| Rate for Payer: Midlands Choice Commercial |
$98.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$71.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$105.00
|
| Rate for Payer: United Healthcare Commercial |
$126.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.60
|
| Rate for Payer: Wellmark IA HMO |
$96.72
|
| Rate for Payer: Wellmark IA PPO |
$106.39
|
|
|
QUEtiapine 100 mg Tab
|
Facility
OP
|
$2.45
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43750173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Aetna of IA Commercial |
$2.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.20
|
| Rate for Payer: Aetna of IA Medicare |
$1.40
|
| Rate for Payer: Amerigroup Medicaid |
$1.24
|
| Rate for Payer: Amerigroup Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.22
|
| Rate for Payer: Medical Associates Commercial |
$1.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.22
|
| Rate for Payer: Midlands Choice Commercial |
$1.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$2.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.45
|
|
|
QUEtiapine 100 mg Tab
|
Facility
IP
|
$2.45
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43750173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Aetna of IA Commercial |
$2.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.20
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.84
|
| Rate for Payer: Medical Associates Commercial |
$1.84
|
| Rate for Payer: Midlands Choice Commercial |
$1.72
|
| Rate for Payer: United Healthcare Commercial |
$2.20
|
|
|
QUEtiapine 25 mg Tab
|
Facility
OP
|
$1.13
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43703188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Aetna of IA Medicare |
$0.64
|
| Rate for Payer: Amerigroup Medicaid |
$0.57
|
| Rate for Payer: Amerigroup Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.56
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.57
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.67
|
|
|
QUEtiapine 25 mg Tab
|
Facility
IP
|
$1.13
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43703188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
|
|
QUICKFIX SCREW 2X10MM
|
Facility
OP
|
$432.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8852325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$215.91 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Aetna of IA Medicare |
$246.24
|
| Rate for Payer: Amerigroup Medicaid |
$218.03
|
| Rate for Payer: Amerigroup Medicare |
$218.16
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$216.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$215.91
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$216.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$219.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$324.00
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$254.88
|
|
|
QUICKFIX SCREW 2X10MM
|
Facility
IP
|
$432.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8852325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$302.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
|
|
QUICKFIX SCREW 2X11MM
|
Facility
OP
|
$432.00
|
|
|
Service Code
|
CPT C1783
|
| Hospital Charge Code |
8463228
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$215.91 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Aetna of IA Medicare |
$246.24
|
| Rate for Payer: Amerigroup Medicaid |
$218.03
|
| Rate for Payer: Amerigroup Medicare |
$218.16
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$216.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$215.91
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$216.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$219.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$324.00
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$254.88
|
|
|
QUICKFIX SCREW 2X11MM
|
Facility
IP
|
$432.00
|
|
|
Service Code
|
CPT C1783
|
| Hospital Charge Code |
8463228
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$302.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
|
|
QUICKFIX SCREW 2X13MM
|
Facility
IP
|
$432.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8852327
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$302.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
|
|
QUICKFIX SCREW 2X13MM
|
Facility
OP
|
$432.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8852327
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$215.91 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Aetna of IA Medicare |
$246.24
|
| Rate for Payer: Amerigroup Medicaid |
$218.03
|
| Rate for Payer: Amerigroup Medicare |
$218.16
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$216.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$215.91
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$216.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$219.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$324.00
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$254.88
|
|
|
quiNIDine 200 mg Tab
|
Facility
OP
|
$1.78
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43786559
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of IA Commercial |
$1.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.60
|
| Rate for Payer: Aetna of IA Medicare |
$1.01
|
| Rate for Payer: Amerigroup Medicaid |
$0.90
|
| Rate for Payer: Amerigroup Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.89
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.05
|
|
|
quiNIDine 200 mg Tab
|
Facility
IP
|
$1.78
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43786559
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of IA Commercial |
$1.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.60
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.34
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: United Healthcare Commercial |
$1.60
|
|
|
Qutenza Administration Charge
|
Facility
OP
|
$200.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
8964103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.96 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna of IA Commercial |
$180.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$180.00
|
| Rate for Payer: Aetna of IA Medicare |
$114.00
|
| Rate for Payer: Amerigroup Medicaid |
$100.94
|
| Rate for Payer: Amerigroup Medicare |
$101.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$150.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$100.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$99.96
|
| Rate for Payer: Medical Associates Commercial |
$150.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$100.00
|
| Rate for Payer: Midlands Choice Commercial |
$140.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$101.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$150.00
|
| Rate for Payer: United Healthcare Commercial |
$180.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$118.00
|
|
|
Qutenza Administration Charge
|
Facility
IP
|
$200.00
|
|
|
Service Code
|
CPT G0463
|
| Hospital Charge Code |
8964103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna of IA Commercial |
$180.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$180.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$150.00
|
| Rate for Payer: Medical Associates Commercial |
$150.00
|
| Rate for Payer: Midlands Choice Commercial |
$140.00
|
| Rate for Payer: United Healthcare Commercial |
$180.00
|
|
|
rabies immune globulin, human 150 intl units/mL 2ml IM SDV
|
Facility
OP
|
$3,530.00
|
|
|
Service Code
|
CPT 90376
|
| Hospital Charge Code |
43705828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$583.42 |
| Max. Negotiated Rate |
$3,177.00 |
| Rate for Payer: Aetna of IA Commercial |
$3,177.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,177.00
|
| Rate for Payer: Aetna of IA Medicare |
$2,012.10
|
| Rate for Payer: Amerigroup Medicaid |
$1,781.59
|
| Rate for Payer: Amerigroup Medicare |
$1,782.65
|
| Rate for Payer: Cash Price |
$2,824.00
|
| Rate for Payer: Cash Price |
$2,824.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,647.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,765.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,764.29
|
| Rate for Payer: Medical Associates Commercial |
$2,647.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,765.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,471.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,791.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,647.50
|
| Rate for Payer: United Healthcare Commercial |
$3,177.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,082.70
|
| Rate for Payer: Wellmark IA HMO |
$583.42
|
| Rate for Payer: Wellmark IA PPO |
$641.76
|
|
|
rabies immune globulin, human 150 intl units/mL 2ml IM SDV
|
Facility
IP
|
$3,530.00
|
|
|
Service Code
|
CPT 90376
|
| Hospital Charge Code |
43705828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,471.00 |
| Max. Negotiated Rate |
$3,177.00 |
| Rate for Payer: Aetna of IA Commercial |
$3,177.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,177.00
|
| Rate for Payer: Cash Price |
$2,824.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,647.50
|
| Rate for Payer: Medical Associates Commercial |
$2,647.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,471.00
|
| Rate for Payer: United Healthcare Commercial |
$3,177.00
|
|
|
rabies vaccine, purified chick embryo cell 2.5 intl units SDV Pow
|
Facility
OP
|
$1,542.88
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
43705829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$207.70 |
| Max. Negotiated Rate |
$1,388.59 |
| Rate for Payer: Aetna of IA Commercial |
$1,388.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,388.59
|
| Rate for Payer: Aetna of IA Medicare |
$879.44
|
| Rate for Payer: Amerigroup Medicaid |
$778.69
|
| Rate for Payer: Amerigroup Medicare |
$779.15
|
| Rate for Payer: Cash Price |
$1,234.30
|
| Rate for Payer: Cash Price |
$1,234.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,157.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$771.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$771.13
|
| Rate for Payer: Medical Associates Commercial |
$1,157.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$771.44
|
| Rate for Payer: Midlands Choice Commercial |
$1,080.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$783.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,157.16
|
| Rate for Payer: United Healthcare Commercial |
$1,388.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$910.30
|
| Rate for Payer: Wellmark IA HMO |
$207.70
|
| Rate for Payer: Wellmark IA PPO |
$228.47
|
|
|
rabies vaccine, purified chick embryo cell 2.5 intl units SDV Pow
|
Facility
IP
|
$1,542.88
|
|
|
Service Code
|
CPT 90675
|
| Hospital Charge Code |
43705829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,080.02 |
| Max. Negotiated Rate |
$1,388.59 |
| Rate for Payer: Aetna of IA Commercial |
$1,388.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,388.59
|
| Rate for Payer: Cash Price |
$1,234.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,157.16
|
| Rate for Payer: Medical Associates Commercial |
$1,157.16
|
| Rate for Payer: Midlands Choice Commercial |
$1,080.02
|
| Rate for Payer: United Healthcare Commercial |
$1,388.59
|
|
|
racepinephrine 2.25% Sol UD
|
Facility
OP
|
$7.67
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43755169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$6.90 |
| Rate for Payer: Aetna of IA Commercial |
$6.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.90
|
| Rate for Payer: Aetna of IA Medicare |
$4.37
|
| Rate for Payer: Amerigroup Medicaid |
$3.87
|
| Rate for Payer: Amerigroup Medicare |
$3.87
|
| Rate for Payer: Cash Price |
$6.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.83
|
| Rate for Payer: Medical Associates Commercial |
$5.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.84
|
| Rate for Payer: Midlands Choice Commercial |
$5.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.75
|
| Rate for Payer: United Healthcare Commercial |
$6.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.53
|
|
|
racepinephrine 2.25% Sol UD
|
Facility
IP
|
$7.67
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43755169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$6.90 |
| Rate for Payer: Aetna of IA Commercial |
$6.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.90
|
| Rate for Payer: Cash Price |
$6.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.75
|
| Rate for Payer: Medical Associates Commercial |
$5.75
|
| Rate for Payer: Midlands Choice Commercial |
$5.37
|
| Rate for Payer: United Healthcare Commercial |
$6.90
|
|
|
Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)
|
Facility
OP
|
$3,598.91
|
|
|
Service Code
|
CPT 64625
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,271.74 |
| Max. Negotiated Rate |
$3,598.91 |
| Rate for Payer: Wellmark IA HMO |
$3,271.74
|
| Rate for Payer: Wellmark IA PPO |
$3,598.91
|
|
|
Radiotherapy
|
Facility
IP
|
$24,488.92
|
|
|
Service Code
|
MS-DRG 849
|
| Hospital Charge Code |
591
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$24,488.92 |
| Rate for Payer: Amerigroup Medicaid |
$24,370.61
|
| 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 |
$24,134.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24,488.92
|
|
