|
acyclovir 400 mg Tab [VDMC]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10363815
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Aetna of IA Medicare |
$0.71
|
| Rate for Payer: Amerigroup Medicaid |
$0.72
|
| Rate for Payer: Amerigroup Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.93
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.71
|
| Rate for Payer: Medical Associates Commercial |
$0.93
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.56
|
| Rate for Payer: Midlands Choice Commercial |
$0.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.64
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.73
|
|
|
acyclovir 50 mg/mL IV Sol 20 ml SDV [VDMC]
|
Facility
|
IP
|
$36.47
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
10363886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.53 |
| Max. Negotiated Rate |
$32.82 |
| Rate for Payer: Aetna of IA Commercial |
$32.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.82
|
| Rate for Payer: Cash Price |
$29.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$27.35
|
| Rate for Payer: Medical Associates Commercial |
$27.35
|
| Rate for Payer: Midlands Choice Commercial |
$25.53
|
| Rate for Payer: United Healthcare Commercial |
$32.82
|
|
|
acyclovir 50 mg/mL IV Sol 20 ml SDV [VDMC]
|
Facility
|
OP
|
$36.47
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
10363886
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.41 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$32.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.82
|
| Rate for Payer: Aetna of IA Medicare |
$20.79
|
| Rate for Payer: Amerigroup Medicaid |
$21.04
|
| Rate for Payer: Amerigroup Medicare |
$16.58
|
| Rate for Payer: Cash Price |
$29.18
|
| Rate for Payer: Cash Price |
$29.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$27.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$16.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.83
|
| Rate for Payer: Medical Associates Commercial |
$27.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.41
|
| Rate for Payer: Midlands Choice Commercial |
$25.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.87
|
| Rate for Payer: United Healthcare Commercial |
$32.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$21.52
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ADAPTOR UNION SCREW
|
Facility
|
IP
|
$956.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047296
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$669.20 |
| Max. Negotiated Rate |
$860.40 |
| Rate for Payer: Aetna of IA Commercial |
$860.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$860.40
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$717.00
|
| Rate for Payer: Medical Associates Commercial |
$717.00
|
| Rate for Payer: Midlands Choice Commercial |
$669.20
|
| Rate for Payer: United Healthcare Commercial |
$860.40
|
|
|
ADAPTOR UNION SCREW
|
Facility
|
OP
|
$956.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047296
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.20 |
| Max. Negotiated Rate |
$860.40 |
| Rate for Payer: Aetna of IA Commercial |
$860.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$860.40
|
| Rate for Payer: Aetna of IA Medicare |
$544.92
|
| Rate for Payer: Amerigroup Medicaid |
$551.42
|
| Rate for Payer: Amerigroup Medicare |
$434.50
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$717.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$430.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$546.07
|
| Rate for Payer: Medical Associates Commercial |
$717.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$430.20
|
| Rate for Payer: Midlands Choice Commercial |
$669.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$554.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$494.73
|
| Rate for Payer: United Healthcare Commercial |
$860.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$564.04
|
|
|
ADD ON CODE FOR INTERACTIVE COMPLEXITY (ED)
|
Professional
|
Both
|
$22.00
|
|
|
Service Code
|
CPT 90785 AJ|HO
|
| Hospital Charge Code |
4919421
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$24.02 |
| Rate for Payer: Amerigroup Medicaid |
$4.45
|
| Rate for Payer: Cash Price |
$17.60
|
| Rate for Payer: Cash Price |
$17.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.41
|
| Rate for Payer: Medical Associates Commercial |
$16.50
|
| Rate for Payer: Midlands Choice Commercial |
$15.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.43
|
| Rate for Payer: Optum Behavioral Health |
$14.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.50
|
| Rate for Payer: United Healthcare Commercial |
$24.02
|
| Rate for Payer: Wellmark IA HMO WHPI |
$19.80
|
| Rate for Payer: Wellmark IA PPO |
$19.80
|
|
|
adenosine 3 mg/mL 2 ml syringe SDS [VDMC]
|
Facility
|
OP
|
$78.50
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
10364026
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.32 |
| Max. Negotiated Rate |
$70.65 |
| Rate for Payer: Aetna of IA Commercial |
$70.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.65
|
| Rate for Payer: Aetna of IA Medicare |
$44.74
|
| Rate for Payer: Amerigroup Medicaid |
$45.28
|
| Rate for Payer: Amerigroup Medicare |
$35.68
|
| Rate for Payer: Cash Price |
$62.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$35.32
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$44.84
|
| Rate for Payer: Medical Associates Commercial |
$58.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$35.32
|
| Rate for Payer: Midlands Choice Commercial |
$54.95
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$45.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.62
|
| Rate for Payer: United Healthcare Commercial |
$70.65
|
| Rate for Payer: United Healthcare Managed Medicare |
$46.32
|
|
|
adenosine 3 mg/mL 2 ml syringe SDS [VDMC]
|
Facility
|
IP
|
$78.50
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
10364026
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$70.65 |
| Rate for Payer: Aetna of IA Commercial |
$70.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.65
|
| Rate for Payer: Cash Price |
$62.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.88
|
| Rate for Payer: Medical Associates Commercial |
$58.88
|
| Rate for Payer: Midlands Choice Commercial |
$54.95
|
| Rate for Payer: United Healthcare Commercial |
$70.65
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$3,434.06
|
|
|
Service Code
|
CPT 14040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,117.47 |
| Max. Negotiated Rate |
$3,434.06 |
| Rate for Payer: Wellmark IA HMO WHPI |
$3,117.47
|
| Rate for Payer: Wellmark IA PPO |
$3,434.06
|
|
|
ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<
|
Professional
|
Both
|
$2,531.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
8799105
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$541.27 |
| Max. Negotiated Rate |
$1,898.25 |
| Rate for Payer: Amerigroup Medicaid |
$546.58
|
| Rate for Payer: Cash Price |
$2,024.80
|
| Rate for Payer: Cash Price |
$2,024.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$541.27
|
| Rate for Payer: Medical Associates Commercial |
$1,898.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,771.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$543.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,898.25
|
| Rate for Payer: United Healthcare Commercial |
$1,147.18
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,393.00
|
| Rate for Payer: Wellmark IA PPO |
$1,638.80
|
|
|
ADL TRAINING EA 15 MIN
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 97535 GO
|
| Hospital Charge Code |
1373569
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna of IA Commercial |
$97.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.20
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.00
|
| Rate for Payer: Medical Associates Commercial |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$75.60
|
| Rate for Payer: United Healthcare Commercial |
$97.20
|
|
|
ADL TRAINING EA 15 MIN
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 97535 GO
|
| Hospital Charge Code |
1373569
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna of IA Commercial |
$97.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.20
|
| Rate for Payer: Aetna of IA Medicare |
$61.56
|
| Rate for Payer: Amerigroup Medicaid |
$62.29
|
| Rate for Payer: Amerigroup Medicare |
$49.09
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$48.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$61.69
|
| Rate for Payer: Medical Associates Commercial |
$81.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$48.60
|
| Rate for Payer: Midlands Choice Commercial |
$75.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$62.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$55.89
|
| Rate for Payer: United Healthcare Commercial |
$97.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.72
|
| Rate for Payer: Wellmark IA HMO WHPI |
$73.74
|
| Rate for Payer: Wellmark IA PPO |
$81.22
|
|
|
ADM IM
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
4866834
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$28.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna of IA Commercial |
$57.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.60
|
| Rate for Payer: Aetna of IA Medicare |
$36.48
|
| Rate for Payer: Amerigroup Medicaid |
$36.92
|
| Rate for Payer: Amerigroup Medicare |
$29.09
|
| Rate for Payer: Cash Price |
$51.20
|
| Rate for Payer: Cash Price |
$51.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$36.56
|
| Rate for Payer: Medical Associates Commercial |
$48.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.80
|
| Rate for Payer: Midlands Choice Commercial |
$44.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.12
|
| Rate for Payer: United Healthcare Commercial |
$57.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.76
|
| Rate for Payer: Wellmark IA HMO WHPI |
$37.58
|
| Rate for Payer: Wellmark IA PPO |
$41.39
|
|
|
ADM IM
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
6922826
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Aetna of IA Commercial |
$59.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.40
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.50
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
|
|
ADM IM
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
4866834
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna of IA Commercial |
$57.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.60
|
| Rate for Payer: Cash Price |
$51.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.00
|
| Rate for Payer: Medical Associates Commercial |
$48.00
|
| Rate for Payer: Midlands Choice Commercial |
$44.80
|
| Rate for Payer: United Healthcare Commercial |
$57.60
|
|
|
ADM IM
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
6922826
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Aetna of IA Commercial |
$59.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.40
|
| Rate for Payer: Aetna of IA Medicare |
$37.62
|
| Rate for Payer: Amerigroup Medicaid |
$38.07
|
| Rate for Payer: Amerigroup Medicare |
$30.00
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.70
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.70
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.16
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.94
|
| Rate for Payer: Wellmark IA HMO WHPI |
$37.58
|
| Rate for Payer: Wellmark IA PPO |
$41.39
|
|
|
ADM IM SCHEDULED
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
8012938
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Aetna of IA Commercial |
$59.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.40
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.50
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
|
|
ADM IM SCHEDULED
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
8012938
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Aetna of IA Commercial |
$59.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.40
|
| Rate for Payer: Aetna of IA Medicare |
$37.62
|
| Rate for Payer: Amerigroup Medicaid |
$38.07
|
| Rate for Payer: Amerigroup Medicare |
$30.00
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.70
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.70
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.16
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.94
|
| Rate for Payer: Wellmark IA HMO WHPI |
$37.58
|
| Rate for Payer: Wellmark IA PPO |
$41.39
|
|
|
ADM IM SCHEDULED ADDITIONAL
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 96372 59
|
| Hospital Charge Code |
8012945
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Aetna of IA Commercial |
$59.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.40
|
| Rate for Payer: Aetna of IA Medicare |
$37.62
|
| Rate for Payer: Amerigroup Medicaid |
$38.07
|
| Rate for Payer: Amerigroup Medicare |
$30.00
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.70
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.70
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.16
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.94
|
| Rate for Payer: Wellmark IA HMO WHPI |
$37.58
|
| Rate for Payer: Wellmark IA PPO |
$41.39
|
|
|
ADM IM SCHEDULED ADDITIONAL
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 96372 59
|
| Hospital Charge Code |
8012945
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Aetna of IA Commercial |
$59.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.40
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.50
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
|
|
ADMIN FLU VACCINE
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
8012757
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$41.39 |
| Rate for Payer: Aetna of IA Commercial |
$40.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$40.50
|
| Rate for Payer: Aetna of IA Medicare |
$25.65
|
| Rate for Payer: Amerigroup Medicaid |
$25.96
|
| Rate for Payer: Amerigroup Medicare |
$20.45
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$25.70
|
| Rate for Payer: Medical Associates Commercial |
$33.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.25
|
| Rate for Payer: Midlands Choice Commercial |
$31.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.29
|
| Rate for Payer: United Healthcare Commercial |
$40.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$26.55
|
| Rate for Payer: Wellmark IA HMO WHPI |
$37.58
|
| Rate for Payer: Wellmark IA PPO |
$41.39
|
|
|
ADMIN FLU VACCINE
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
8012757
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna of IA Commercial |
$40.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$40.50
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.75
|
| Rate for Payer: Medical Associates Commercial |
$33.75
|
| Rate for Payer: Midlands Choice Commercial |
$31.50
|
| Rate for Payer: United Healthcare Commercial |
$40.50
|
|
|
ADMINISTER IM CHARGE
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
8068907
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Amerigroup Medicaid |
$3.88
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.85
|
| Rate for Payer: Medical Associates Commercial |
$33.75
|
| Rate for Payer: Midlands Choice Commercial |
$31.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.75
|
| Rate for Payer: United Healthcare Commercial |
$21.58
|
| Rate for Payer: Wellmark IA HMO WHPI |
$26.10
|
| Rate for Payer: Wellmark IA PPO |
$30.70
|
|
|
ADMIN PNEUMOVAC VACCINE
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
8012758
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$41.39 |
| Rate for Payer: Aetna of IA Commercial |
$13.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.50
|
| Rate for Payer: Aetna of IA Medicare |
$8.55
|
| Rate for Payer: Amerigroup Medicaid |
$8.65
|
| Rate for Payer: Amerigroup Medicare |
$6.82
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.57
|
| Rate for Payer: Medical Associates Commercial |
$11.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.75
|
| Rate for Payer: Midlands Choice Commercial |
$10.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.76
|
| Rate for Payer: United Healthcare Commercial |
$13.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.85
|
| Rate for Payer: Wellmark IA HMO WHPI |
$37.58
|
| Rate for Payer: Wellmark IA PPO |
$41.39
|
|
|
ADMIN PNEUMOVAC VACCINE
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
8012758
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna of IA Commercial |
$13.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.50
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.25
|
| Rate for Payer: Medical Associates Commercial |
$11.25
|
| Rate for Payer: Midlands Choice Commercial |
$10.50
|
| Rate for Payer: United Healthcare Commercial |
$13.50
|
|
