|
rOPINIRole 1 mg Tab [VDMC]
|
Facility
|
OP
|
$2.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419836
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of IA Commercial |
$1.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.94
|
| Rate for Payer: Aetna of IA Medicare |
$1.23
|
| Rate for Payer: Amerigroup Medicaid |
$1.24
|
| Rate for Payer: Amerigroup Medicare |
$0.98
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.61
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.23
|
| Rate for Payer: Medical Associates Commercial |
$1.61
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.97
|
| Rate for Payer: Midlands Choice Commercial |
$1.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.27
|
|
|
rOPINIRole 1 mg Tab [VDMC]
|
Facility
|
IP
|
$2.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419836
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of IA Commercial |
$1.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.94
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.61
|
| Rate for Payer: Medical Associates Commercial |
$1.61
|
| Rate for Payer: Midlands Choice Commercial |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$1.94
|
|
|
ropivacaine 0.5% 30 mL SDV [VDMC]
|
Facility
|
OP
|
$38.39
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
10440103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.28 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$34.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.55
|
| Rate for Payer: Aetna of IA Medicare |
$21.88
|
| Rate for Payer: Amerigroup Medicaid |
$22.14
|
| Rate for Payer: Amerigroup Medicare |
$17.45
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.79
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.93
|
| Rate for Payer: Medical Associates Commercial |
$28.79
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.28
|
| Rate for Payer: Midlands Choice Commercial |
$26.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.87
|
| Rate for Payer: United Healthcare Commercial |
$34.55
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.65
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ropivacaine 0.5% 30 mL SDV [VDMC]
|
Facility
|
IP
|
$38.39
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
10440103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.87 |
| Max. Negotiated Rate |
$34.55 |
| Rate for Payer: Aetna of IA Commercial |
$34.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.55
|
| Rate for Payer: Cash Price |
$30.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.79
|
| Rate for Payer: Medical Associates Commercial |
$28.79
|
| Rate for Payer: Midlands Choice Commercial |
$26.87
|
| Rate for Payer: United Healthcare Commercial |
$34.55
|
|
|
rosuvastatin 10 mg Tab [VDMC]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419905
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of IA Commercial |
$2.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.16
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.80
|
| Rate for Payer: Medical Associates Commercial |
$1.80
|
| Rate for Payer: Midlands Choice Commercial |
$1.68
|
| Rate for Payer: United Healthcare Commercial |
$2.16
|
|
|
rosuvastatin 10 mg Tab [VDMC]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419905
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of IA Commercial |
$2.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.16
|
| Rate for Payer: Aetna of IA Medicare |
$1.37
|
| Rate for Payer: Amerigroup Medicaid |
$1.39
|
| Rate for Payer: Amerigroup Medicare |
$1.09
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.37
|
| Rate for Payer: Medical Associates Commercial |
$1.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$2.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.42
|
|
|
ROTAVIRUS ANTIGEN DETECTION
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT 87425
|
| Hospital Charge Code |
4024784
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$34.03 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna of IA Commercial |
$88.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.20
|
| Rate for Payer: Aetna of IA Medicare |
$55.86
|
| Rate for Payer: Amerigroup Medicaid |
$56.53
|
| Rate for Payer: Amerigroup Medicare |
$44.54
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$73.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$44.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.98
|
| Rate for Payer: Medical Associates Commercial |
$73.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$44.10
|
| Rate for Payer: Midlands Choice Commercial |
$68.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$50.72
|
| Rate for Payer: United Healthcare Commercial |
$88.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$57.82
|
| Rate for Payer: Wellmark IA HMO WHPI |
$34.03
|
| Rate for Payer: Wellmark IA PPO |
$37.49
|
|
|
ROTAVIRUS ANTIGEN DETECTION
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
CPT 87425
|
| Hospital Charge Code |
4024784
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna of IA Commercial |
$88.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.20
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$73.50
|
| Rate for Payer: Medical Associates Commercial |
$73.50
|
| Rate for Payer: Midlands Choice Commercial |
$68.60
|
| Rate for Payer: United Healthcare Commercial |
$88.20
|
|
|
rotavirus vaccine monovalent Sus UD[VDMC]
|
Facility
|
OP
|
$225.71
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
27810341
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.12 |
| Max. Negotiated Rate |
$203.14 |
| Rate for Payer: Aetna of IA Commercial |
$203.14
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$203.14
|
| Rate for Payer: Aetna of IA Medicare |
$128.65
|
| Rate for Payer: Amerigroup Medicaid |
$130.19
|
| Rate for Payer: Amerigroup Medicare |
$102.58
|
| Rate for Payer: Cash Price |
$180.57
|
| Rate for Payer: Cash Price |
$180.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$169.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$101.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$128.92
|
| Rate for Payer: Medical Associates Commercial |
$169.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$101.57
|
| Rate for Payer: Midlands Choice Commercial |
$158.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$130.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$116.80
|
| Rate for Payer: United Healthcare Commercial |
$203.14
|
| Rate for Payer: United Healthcare Managed Medicare |
$133.17
|
| Rate for Payer: Wellmark IA HMO WHPI |
$80.12
|
| Rate for Payer: Wellmark IA PPO |
$88.25
|
|
|
rotavirus vaccine monovalent Sus UD[VDMC]
|
Facility
|
IP
|
$225.71
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
27810341
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$203.14 |
| Rate for Payer: Aetna of IA Commercial |
$203.14
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$203.14
|
| Rate for Payer: Cash Price |
$180.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$169.28
|
| Rate for Payer: Medical Associates Commercial |
$169.28
|
| Rate for Payer: Midlands Choice Commercial |
$158.00
|
| Rate for Payer: United Healthcare Commercial |
$203.14
|
|
|
rotavirus vaccine pentavalent Sus UD[VDMC]
|
Facility
|
OP
|
$177.82
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
12453538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.02 |
| Max. Negotiated Rate |
$400.65 |
| Rate for Payer: Aetna of IA Commercial |
$160.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$160.03
|
| Rate for Payer: Aetna of IA Medicare |
$101.36
|
| Rate for Payer: Amerigroup Medicaid |
$102.56
|
| Rate for Payer: Amerigroup Medicare |
$80.82
|
| Rate for Payer: Cash Price |
$142.25
|
| Rate for Payer: Cash Price |
$142.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$133.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$80.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$101.57
|
| Rate for Payer: Medical Associates Commercial |
$133.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$80.02
|
| Rate for Payer: Midlands Choice Commercial |
$124.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$103.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$92.02
|
| Rate for Payer: United Healthcare Commercial |
$160.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$104.91
|
| Rate for Payer: Wellmark IA HMO WHPI |
$363.72
|
| Rate for Payer: Wellmark IA PPO |
$400.65
|
|
|
rotavirus vaccine pentavalent Sus UD[VDMC]
|
Facility
|
IP
|
$177.82
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
12453538
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.47 |
| Max. Negotiated Rate |
$160.03 |
| Rate for Payer: Aetna of IA Commercial |
$160.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$160.03
|
| Rate for Payer: Cash Price |
$142.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$133.36
|
| Rate for Payer: Medical Associates Commercial |
$133.36
|
| Rate for Payer: Midlands Choice Commercial |
$124.47
|
| Rate for Payer: United Healthcare Commercial |
$160.03
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 CM
|
Professional
|
Both
|
$675.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
7982835
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$245.80 |
| Max. Negotiated Rate |
$506.25 |
| Rate for Payer: Amerigroup Medicaid |
$248.21
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$245.80
|
| Rate for Payer: Medical Associates Commercial |
$506.25
|
| Rate for Payer: Midlands Choice Commercial |
$472.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$247.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$506.25
|
| Rate for Payer: United Healthcare Commercial |
$322.51
|
| Rate for Payer: Wellmark IA HMO WHPI |
$399.90
|
| Rate for Payer: Wellmark IA PPO |
$470.50
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
4863336
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$154.35 |
| Max. Negotiated Rate |
$657.60 |
| Rate for Payer: Aetna of IA Commercial |
$308.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$308.70
|
| Rate for Payer: Aetna of IA Medicare |
$195.51
|
| Rate for Payer: Amerigroup Medicaid |
$197.84
|
| Rate for Payer: Amerigroup Medicare |
$155.89
|
| Rate for Payer: Cash Price |
$274.40
|
| Rate for Payer: Cash Price |
$274.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$257.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$154.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$195.92
|
| Rate for Payer: Medical Associates Commercial |
$257.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$154.35
|
| Rate for Payer: Midlands Choice Commercial |
$240.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$198.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$177.50
|
| Rate for Payer: United Healthcare Commercial |
$308.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$202.37
|
| Rate for Payer: Wellmark IA HMO WHPI |
$596.98
|
| Rate for Payer: Wellmark IA PPO |
$657.60
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
4863336
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$240.10 |
| Max. Negotiated Rate |
$308.70 |
| Rate for Payer: Aetna of IA Commercial |
$308.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$308.70
|
| Rate for Payer: Cash Price |
$274.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$257.25
|
| Rate for Payer: Medical Associates Commercial |
$257.25
|
| Rate for Payer: Midlands Choice Commercial |
$240.10
|
| Rate for Payer: United Healthcare Commercial |
$308.70
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<
|
Professional
|
Both
|
$280.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
7982839
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$118.88 |
| Max. Negotiated Rate |
$241.70 |
| Rate for Payer: Amerigroup Medicaid |
$120.05
|
| Rate for Payer: Cash Price |
$224.00
|
| Rate for Payer: Cash Price |
$224.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$118.88
|
| Rate for Payer: Medical Associates Commercial |
$210.00
|
| Rate for Payer: Midlands Choice Commercial |
$196.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$119.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$210.00
|
| Rate for Payer: United Healthcare Commercial |
$164.86
|
| Rate for Payer: Wellmark IA HMO WHPI |
$205.40
|
| Rate for Payer: Wellmark IA PPO |
$241.70
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
CPT 12013
|
| Hospital Charge Code |
4863337
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$212.80 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna of IA Commercial |
$273.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$273.60
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.00
|
| Rate for Payer: Medical Associates Commercial |
$228.00
|
| Rate for Payer: Midlands Choice Commercial |
$212.80
|
| Rate for Payer: United Healthcare Commercial |
$273.60
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
CPT 12013
|
| Hospital Charge Code |
7982838
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$134.78 |
| Max. Negotiated Rate |
$251.70 |
| Rate for Payer: Amerigroup Medicaid |
$136.10
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.78
|
| Rate for Payer: Medical Associates Commercial |
$206.25
|
| Rate for Payer: Midlands Choice Commercial |
$192.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$135.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$206.25
|
| Rate for Payer: United Healthcare Commercial |
$172.16
|
| Rate for Payer: Wellmark IA HMO WHPI |
$213.90
|
| Rate for Payer: Wellmark IA PPO |
$251.70
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT 12013
|
| Hospital Charge Code |
4863337
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$136.80 |
| Max. Negotiated Rate |
$657.60 |
| Rate for Payer: Aetna of IA Commercial |
$273.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$273.60
|
| Rate for Payer: Aetna of IA Medicare |
$173.28
|
| Rate for Payer: Amerigroup Medicaid |
$175.35
|
| Rate for Payer: Amerigroup Medicare |
$138.17
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$136.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$173.64
|
| Rate for Payer: Medical Associates Commercial |
$228.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$136.80
|
| Rate for Payer: Midlands Choice Commercial |
$212.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$176.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$157.32
|
| Rate for Payer: United Healthcare Commercial |
$273.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$179.36
|
| Rate for Payer: Wellmark IA HMO WHPI |
$596.98
|
| Rate for Payer: Wellmark IA PPO |
$657.60
|
|
|
RPR F/E/E/N/L/M 5.1-7.5 CM
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
CPT 12014
|
| Hospital Charge Code |
4863338
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$246.40 |
| Max. Negotiated Rate |
$316.80 |
| Rate for Payer: Aetna of IA Commercial |
$316.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$316.80
|
| Rate for Payer: Cash Price |
$281.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$264.00
|
| Rate for Payer: Medical Associates Commercial |
$264.00
|
| Rate for Payer: Midlands Choice Commercial |
$246.40
|
| Rate for Payer: United Healthcare Commercial |
$316.80
|
|
|
RPR F/E/E/N/L/M 5.1-7.5 CM
|
Professional
|
Both
|
$441.00
|
|
|
Service Code
|
CPT 12014
|
| Hospital Charge Code |
7982837
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$160.09 |
| Max. Negotiated Rate |
$330.75 |
| Rate for Payer: Amerigroup Medicaid |
$161.66
|
| Rate for Payer: Cash Price |
$352.80
|
| Rate for Payer: Cash Price |
$352.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$160.09
|
| Rate for Payer: Medical Associates Commercial |
$330.75
|
| Rate for Payer: Midlands Choice Commercial |
$308.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$160.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$330.75
|
| Rate for Payer: United Healthcare Commercial |
$209.55
|
| Rate for Payer: Wellmark IA HMO WHPI |
$261.30
|
| Rate for Payer: Wellmark IA PPO |
$307.40
|
|
|
RPR F/E/E/N/L/M 5.1-7.5 CM
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
CPT 12014
|
| Hospital Charge Code |
4863338
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$158.40 |
| Max. Negotiated Rate |
$657.60 |
| Rate for Payer: Aetna of IA Commercial |
$316.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$316.80
|
| Rate for Payer: Aetna of IA Medicare |
$200.64
|
| Rate for Payer: Amerigroup Medicaid |
$203.03
|
| Rate for Payer: Amerigroup Medicare |
$159.98
|
| Rate for Payer: Cash Price |
$281.60
|
| Rate for Payer: Cash Price |
$281.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$264.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$158.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$201.06
|
| Rate for Payer: Medical Associates Commercial |
$264.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$158.40
|
| Rate for Payer: Midlands Choice Commercial |
$246.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$204.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$182.16
|
| Rate for Payer: United Healthcare Commercial |
$316.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$207.68
|
| Rate for Payer: Wellmark IA HMO WHPI |
$596.98
|
| Rate for Payer: Wellmark IA PPO |
$657.60
|
|
|
RPR F/E/E/N/L/M 7.6-12.5 CM
|
Facility
|
OP
|
$359.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
4863340
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$161.55 |
| Max. Negotiated Rate |
$657.60 |
| Rate for Payer: Aetna of IA Commercial |
$323.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$323.10
|
| Rate for Payer: Aetna of IA Medicare |
$204.63
|
| Rate for Payer: Amerigroup Medicaid |
$207.07
|
| Rate for Payer: Amerigroup Medicare |
$163.17
|
| Rate for Payer: Cash Price |
$287.20
|
| Rate for Payer: Cash Price |
$287.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$269.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$161.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$205.06
|
| Rate for Payer: Medical Associates Commercial |
$269.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$161.55
|
| Rate for Payer: Midlands Choice Commercial |
$251.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$208.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$185.78
|
| Rate for Payer: United Healthcare Commercial |
$323.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$211.81
|
| Rate for Payer: Wellmark IA HMO WHPI |
$596.98
|
| Rate for Payer: Wellmark IA PPO |
$657.60
|
|
|
RPR F/E/E/N/L/M 7.6-12.5 CM
|
Facility
|
IP
|
$359.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
4863340
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$251.30 |
| Max. Negotiated Rate |
$323.10 |
| Rate for Payer: Aetna of IA Commercial |
$323.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$323.10
|
| Rate for Payer: Cash Price |
$287.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$269.25
|
| Rate for Payer: Medical Associates Commercial |
$269.25
|
| Rate for Payer: Midlands Choice Commercial |
$251.30
|
| Rate for Payer: United Healthcare Commercial |
$323.10
|
|
|
RPR F/E/E/N/L/M 7.6-12.5 CM
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
7982836
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$202.60 |
| Max. Negotiated Rate |
$371.10 |
| Rate for Payer: Amerigroup Medicaid |
$204.59
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$202.60
|
| Rate for Payer: Medical Associates Commercial |
$337.50
|
| Rate for Payer: Midlands Choice Commercial |
$315.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$203.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$337.50
|
| Rate for Payer: United Healthcare Commercial |
$253.52
|
| Rate for Payer: Wellmark IA HMO WHPI |
$315.40
|
| Rate for Payer: Wellmark IA PPO |
$371.10
|
|
