|
Spinal Procedures Without CC/MCC
|
Facility
IP
|
$18,268.51
|
|
|
Service Code
|
MS-DRG 030
|
| Hospital Charge Code |
719
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$18,268.51 |
| Rate for Payer: Amerigroup Medicaid |
$18,180.25
|
| 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 |
$18,003.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18,268.51
|
|
|
SPINAL PUNCTURE LUMBAR
|
Facility
OP
|
$406.00
|
|
|
Service Code
|
CPT 62270
|
| Hospital Charge Code |
8059050
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$202.92 |
| Max. Negotiated Rate |
$1,487.44 |
| Rate for Payer: Aetna of IA Commercial |
$365.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$365.40
|
| Rate for Payer: Aetna of IA Medicare |
$231.42
|
| Rate for Payer: Amerigroup Medicaid |
$204.91
|
| Rate for Payer: Amerigroup Medicare |
$205.03
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$304.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$203.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$202.92
|
| Rate for Payer: Medical Associates Commercial |
$304.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$203.00
|
| Rate for Payer: Midlands Choice Commercial |
$284.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$206.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$304.50
|
| Rate for Payer: United Healthcare Commercial |
$365.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$239.54
|
| Rate for Payer: Wellmark IA HMO |
$1,352.22
|
| Rate for Payer: Wellmark IA PPO |
$1,487.44
|
|
|
SPINAL PUNCTURE LUMBAR
|
Facility
IP
|
$406.00
|
|
|
Service Code
|
CPT 62270
|
| Hospital Charge Code |
8059050
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$284.20 |
| Max. Negotiated Rate |
$365.40 |
| Rate for Payer: Aetna of IA Commercial |
$365.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$365.40
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$304.50
|
| Rate for Payer: Medical Associates Commercial |
$304.50
|
| Rate for Payer: Midlands Choice Commercial |
$284.20
|
| Rate for Payer: United Healthcare Commercial |
$365.40
|
|
|
Spinal Tap Procedure
|
Facility
IP
|
$602.00
|
|
|
Service Code
|
CPT 62270
|
| Hospital Charge Code |
8060782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$421.40 |
| Max. Negotiated Rate |
$541.80 |
| Rate for Payer: Aetna of IA Commercial |
$541.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$541.80
|
| Rate for Payer: Cash Price |
$481.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$451.50
|
| Rate for Payer: Medical Associates Commercial |
$451.50
|
| Rate for Payer: Midlands Choice Commercial |
$421.40
|
| Rate for Payer: United Healthcare Commercial |
$541.80
|
|
|
Spinal Tap Procedure
|
Facility
OP
|
$602.00
|
|
|
Service Code
|
CPT 62270
|
| Hospital Charge Code |
8060782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.88 |
| Max. Negotiated Rate |
$1,487.44 |
| Rate for Payer: Aetna of IA Commercial |
$541.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$541.80
|
| Rate for Payer: Aetna of IA Medicare |
$343.14
|
| Rate for Payer: Amerigroup Medicaid |
$303.83
|
| Rate for Payer: Amerigroup Medicare |
$304.01
|
| Rate for Payer: Cash Price |
$481.60
|
| Rate for Payer: Cash Price |
$481.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$451.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$301.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$300.88
|
| Rate for Payer: Medical Associates Commercial |
$451.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$301.00
|
| Rate for Payer: Midlands Choice Commercial |
$421.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$305.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$451.50
|
| Rate for Payer: United Healthcare Commercial |
$541.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$355.18
|
| Rate for Payer: Wellmark IA HMO |
$1,352.22
|
| Rate for Payer: Wellmark IA PPO |
$1,487.44
|
|
|
spironolactone 100 mg Tab
|
Facility
IP
|
$1.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of IA Commercial |
$1.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.44
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.20
|
| Rate for Payer: Medical Associates Commercial |
$1.20
|
| Rate for Payer: Midlands Choice Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
|
|
spironolactone 100 mg Tab
|
Facility
OP
|
$1.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of IA Commercial |
$1.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.44
|
| Rate for Payer: Aetna of IA Medicare |
$0.91
|
| Rate for Payer: Amerigroup Medicaid |
$0.81
|
| Rate for Payer: Amerigroup Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.80
|
| Rate for Payer: Medical Associates Commercial |
$1.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.80
|
| Rate for Payer: Midlands Choice Commercial |
$1.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.94
|
|
|
spironolactone 25 mg Tab
|
Facility
IP
|
$1.44
|
|
|
Service Code
|
CPT A4217
|
| Hospital Charge Code |
43700272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
|
|
spironolactone 25 mg Tab
|
Facility
OP
|
$1.44
|
|
|
Service Code
|
CPT A4217
|
| Hospital Charge Code |
43700272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.73
|
| Rate for Payer: Amerigroup Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.72
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.72
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
|
Splenectomy With CC
|
Facility
IP
|
$16,168.14
|
|
|
Service Code
|
MS-DRG 800
|
| Hospital Charge Code |
542
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$16,168.14 |
| Rate for Payer: Amerigroup Medicaid |
$16,090.03
|
| 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 |
$15,933.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16,168.14
|
|
|
Splenectomy With MCC
|
Facility
IP
|
$32,983.90
|
|
|
Service Code
|
MS-DRG 799
|
| Hospital Charge Code |
541
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$32,983.90 |
| Rate for Payer: Amerigroup Medicaid |
$32,824.56
|
| 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 |
$32,505.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32,983.90
|
|
|
Splenectomy Without CC/MCC
|
Facility
IP
|
$13,776.43
|
|
|
Service Code
|
MS-DRG 801
|
| Hospital Charge Code |
543
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$13,776.43 |
| Rate for Payer: Amerigroup Medicaid |
$13,709.88
|
| 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 |
$13,576.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13,776.43
|
|
|
Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh With CC/MCC
|
Facility
IP
|
$7,891.65
|
|
|
Service Code
|
MS-DRG 537
|
| Hospital Charge Code |
344
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,891.65 |
| Rate for Payer: Amerigroup Medicaid |
$7,853.52
|
| 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 |
$7,777.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,891.65
|
|
|
Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh Without CC/MCC
|
Facility
IP
|
$7,100.32
|
|
|
Service Code
|
MS-DRG 538
|
| Hospital Charge Code |
345
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,100.32 |
| Rate for Payer: Amerigroup Medicaid |
$7,066.02
|
| 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 |
$6,997.41
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,100.32
|
|
|
SPRAVATO OBSERVATION
|
Professional
|
$500.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
8829628
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$60.81 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna of IA Medicare |
$60.81
|
| Rate for Payer: Amerigroup Medicaid |
$62.88
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.03
|
| Rate for Payer: Medical Associates Commercial |
$115.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$60.81
|
| Rate for Payer: Midlands Choice Commercial |
$350.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.22
|
| Rate for Payer: United Healthcare Commercial |
$66.26
|
| Rate for Payer: Wellmark IA HMO |
$93.00
|
| Rate for Payer: Wellmark IA PPO |
$93.00
|
|
|
SQ/IM INJECTIONS ADMIN
|
Facility
IP
|
$66.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
7984745
|
|
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
|
|
|
SQ/IM INJECTIONS ADMIN
|
Facility
OP
|
$66.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
7984745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.99 |
| 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 |
$33.31
|
| Rate for Payer: Amerigroup Medicare |
$33.33
|
| 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 |
$33.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.99
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.00
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.94
|
|
|
STANDARD MPJ PLATE, RIGHT
|
Facility
OP
|
$1,914.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8948786
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$956.62 |
| Max. Negotiated Rate |
$1,722.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,722.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,722.60
|
| Rate for Payer: Aetna of IA Medicare |
$1,090.98
|
| Rate for Payer: Amerigroup Medicaid |
$966.00
|
| Rate for Payer: Amerigroup Medicare |
$966.57
|
| Rate for Payer: Cash Price |
$1,531.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,435.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$957.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$956.62
|
| Rate for Payer: Medical Associates Commercial |
$1,435.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$957.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,339.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$971.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,435.50
|
| Rate for Payer: United Healthcare Commercial |
$1,722.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,129.26
|
|
|
STANDARD MPJ PLATE, RIGHT
|
Facility
IP
|
$1,914.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8948786
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,339.80 |
| Max. Negotiated Rate |
$1,722.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,722.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,722.60
|
| Rate for Payer: Cash Price |
$1,531.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,435.50
|
| Rate for Payer: Medical Associates Commercial |
$1,435.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,339.80
|
| Rate for Payer: United Healthcare Commercial |
$1,722.60
|
|
|
STAPLER GIA 60 2.5 MULTIFIRE DISPOSABLE
|
Facility
OP
|
$484.00
|
|
| Hospital Charge Code |
8046475
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$241.90 |
| Max. Negotiated Rate |
$435.60 |
| Rate for Payer: Aetna of IA Commercial |
$435.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$435.60
|
| Rate for Payer: Aetna of IA Medicare |
$275.88
|
| Rate for Payer: Amerigroup Medicaid |
$244.27
|
| Rate for Payer: Amerigroup Medicare |
$244.42
|
| Rate for Payer: Cash Price |
$387.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$363.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$242.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$241.90
|
| Rate for Payer: Medical Associates Commercial |
$363.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$242.00
|
| Rate for Payer: Midlands Choice Commercial |
$338.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$245.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$363.00
|
| Rate for Payer: United Healthcare Commercial |
$435.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$285.56
|
|
|
STAPLER GIA 60 2.5 MULTIFIRE DISPOSABLE
|
Facility
IP
|
$484.00
|
|
| Hospital Charge Code |
8046475
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$338.80 |
| Max. Negotiated Rate |
$435.60 |
| Rate for Payer: Aetna of IA Commercial |
$435.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$435.60
|
| Rate for Payer: Cash Price |
$387.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$363.00
|
| Rate for Payer: Medical Associates Commercial |
$363.00
|
| Rate for Payer: Midlands Choice Commercial |
$338.80
|
| Rate for Payer: United Healthcare Commercial |
$435.60
|
|
|
STENT INJECT
|
Facility
IP
|
$3,636.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8896002
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,545.20 |
| Max. Negotiated Rate |
$3,272.40 |
| Rate for Payer: Aetna of IA Commercial |
$3,272.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,272.40
|
| Rate for Payer: Cash Price |
$2,908.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,727.00
|
| Rate for Payer: Medical Associates Commercial |
$2,727.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,545.20
|
| Rate for Payer: United Healthcare Commercial |
$3,272.40
|
|
|
STENT INJECT
|
Facility
OP
|
$3,636.00
|
|
|
Service Code
|
CPT V2632
|
| Hospital Charge Code |
8896002
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,817.27 |
| Max. Negotiated Rate |
$3,272.40 |
| Rate for Payer: Aetna of IA Commercial |
$3,272.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,272.40
|
| Rate for Payer: Aetna of IA Medicare |
$2,072.52
|
| Rate for Payer: Amerigroup Medicaid |
$1,835.09
|
| Rate for Payer: Amerigroup Medicare |
$1,836.18
|
| Rate for Payer: Cash Price |
$2,908.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,727.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,818.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,817.27
|
| Rate for Payer: Medical Associates Commercial |
$2,727.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,818.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,545.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,845.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,727.00
|
| Rate for Payer: United Healthcare Commercial |
$3,272.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,145.24
|
|
|
Sterile Water Injection 1000ml bag
|
Facility
IP
|
$69.60
|
|
|
Service Code
|
CPT J0330
|
| Hospital Charge Code |
43701648
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$62.64 |
| Rate for Payer: Aetna of IA Commercial |
$62.64
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$62.64
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.20
|
| Rate for Payer: Medical Associates Commercial |
$52.20
|
| Rate for Payer: Midlands Choice Commercial |
$48.72
|
| Rate for Payer: United Healthcare Commercial |
$62.64
|
|
|
Sterile Water Injection 1000ml bag
|
Facility
OP
|
$69.60
|
|
|
Service Code
|
CPT J0330
|
| Hospital Charge Code |
43701648
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.79 |
| Max. Negotiated Rate |
$62.64 |
| Rate for Payer: Aetna of IA Commercial |
$62.64
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$62.64
|
| Rate for Payer: Aetna of IA Medicare |
$39.67
|
| Rate for Payer: Amerigroup Medicaid |
$35.13
|
| Rate for Payer: Amerigroup Medicare |
$35.15
|
| Rate for Payer: Cash Price |
$55.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$34.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$34.79
|
| Rate for Payer: Medical Associates Commercial |
$52.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$34.80
|
| Rate for Payer: Midlands Choice Commercial |
$48.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$52.20
|
| Rate for Payer: United Healthcare Commercial |
$62.64
|
| Rate for Payer: United Healthcare Managed Medicare |
$41.06
|
|
