|
terbinafine topical 1% Cre 15gm [VDMC]
|
Facility
|
IP
|
$33.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11337009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.18 |
| Max. Negotiated Rate |
$29.81 |
| Rate for Payer: Aetna of IA Commercial |
$29.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.81
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.84
|
| Rate for Payer: Medical Associates Commercial |
$24.84
|
| Rate for Payer: Midlands Choice Commercial |
$23.18
|
| Rate for Payer: United Healthcare Commercial |
$29.81
|
|
|
terbinafine topical 1% Cre 15gm [VDMC]
|
Facility
|
OP
|
$33.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11337009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.90 |
| Max. Negotiated Rate |
$29.81 |
| Rate for Payer: Aetna of IA Commercial |
$29.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.81
|
| Rate for Payer: Aetna of IA Medicare |
$18.88
|
| Rate for Payer: Amerigroup Medicaid |
$19.10
|
| Rate for Payer: Amerigroup Medicare |
$15.05
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.92
|
| Rate for Payer: Medical Associates Commercial |
$24.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.90
|
| Rate for Payer: Midlands Choice Commercial |
$23.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.14
|
| Rate for Payer: United Healthcare Commercial |
$29.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.54
|
|
|
terbutaline 1 mg/mL 1 ml Inj SDV [VDMC]
|
Facility
|
IP
|
$25.41
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
10424044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.79 |
| Max. Negotiated Rate |
$22.87 |
| Rate for Payer: Aetna of IA Commercial |
$22.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.87
|
| Rate for Payer: Cash Price |
$20.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.06
|
| Rate for Payer: Medical Associates Commercial |
$19.06
|
| Rate for Payer: Midlands Choice Commercial |
$17.79
|
| Rate for Payer: United Healthcare Commercial |
$22.87
|
|
|
terbutaline 1 mg/mL 1 ml Inj SDV [VDMC]
|
Facility
|
OP
|
$25.41
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
10424044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$22.87 |
| Rate for Payer: Aetna of IA Commercial |
$22.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.87
|
| Rate for Payer: Aetna of IA Medicare |
$14.48
|
| Rate for Payer: Amerigroup Medicaid |
$14.66
|
| Rate for Payer: Amerigroup Medicare |
$11.55
|
| Rate for Payer: Cash Price |
$20.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.52
|
| Rate for Payer: Medical Associates Commercial |
$19.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.44
|
| Rate for Payer: Midlands Choice Commercial |
$17.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.15
|
| Rate for Payer: United Healthcare Commercial |
$22.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.99
|
|
|
TEST IMPLANT
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8753463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna of IA Commercial |
$900.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$900.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$750.00
|
| Rate for Payer: Medical Associates Commercial |
$750.00
|
| Rate for Payer: Midlands Choice Commercial |
$700.00
|
| Rate for Payer: United Healthcare Commercial |
$900.00
|
|
|
TEST IMPLANT
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8753463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna of IA Commercial |
$900.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$900.00
|
| Rate for Payer: Aetna of IA Medicare |
$570.00
|
| Rate for Payer: Amerigroup Medicaid |
$576.80
|
| Rate for Payer: Amerigroup Medicare |
$454.50
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$750.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$450.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$571.20
|
| Rate for Payer: Medical Associates Commercial |
$750.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$450.00
|
| Rate for Payer: Midlands Choice Commercial |
$700.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$579.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$517.50
|
| Rate for Payer: United Healthcare Commercial |
$900.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$590.00
|
|
|
testosterone 75 mg Imp[VDMC]
|
Facility
|
IP
|
$351.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
12491246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$245.90 |
| Max. Negotiated Rate |
$316.16 |
| Rate for Payer: Aetna of IA Commercial |
$316.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$316.16
|
| Rate for Payer: Cash Price |
$281.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$263.46
|
| Rate for Payer: Medical Associates Commercial |
$263.46
|
| Rate for Payer: Midlands Choice Commercial |
$245.90
|
| Rate for Payer: United Healthcare Commercial |
$316.16
|
|
|
testosterone 75 mg Imp[VDMC]
|
Facility
|
OP
|
$351.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
12491246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$158.08 |
| Max. Negotiated Rate |
$316.16 |
| Rate for Payer: Aetna of IA Commercial |
$316.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$316.16
|
| Rate for Payer: Aetna of IA Medicare |
$200.23
|
| Rate for Payer: Amerigroup Medicaid |
$202.62
|
| Rate for Payer: Amerigroup Medicare |
$159.66
|
| Rate for Payer: Cash Price |
$281.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$263.46
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$158.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$200.65
|
| Rate for Payer: Medical Associates Commercial |
$263.46
|
| Rate for Payer: Medical Associates Managed Medicare |
$158.08
|
| Rate for Payer: Midlands Choice Commercial |
$245.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$203.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$181.79
|
| Rate for Payer: United Healthcare Commercial |
$316.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$207.26
|
|
|
testosterone cypionate 200 mg/mL 1 ml IM SDV [VDMC]
|
Facility
|
OP
|
$107.16
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
10424113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.22 |
| Max. Negotiated Rate |
$96.44 |
| Rate for Payer: Aetna of IA Commercial |
$96.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$96.44
|
| Rate for Payer: Aetna of IA Medicare |
$61.08
|
| Rate for Payer: Amerigroup Medicaid |
$61.81
|
| Rate for Payer: Amerigroup Medicare |
$48.70
|
| Rate for Payer: Cash Price |
$85.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.37
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$48.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$61.21
|
| Rate for Payer: Medical Associates Commercial |
$80.37
|
| Rate for Payer: Medical Associates Managed Medicare |
$48.22
|
| Rate for Payer: Midlands Choice Commercial |
$75.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$62.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$55.46
|
| Rate for Payer: United Healthcare Commercial |
$96.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.22
|
|
|
testosterone cypionate 200 mg/mL 1 ml IM SDV [VDMC]
|
Facility
|
IP
|
$107.16
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
10424113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$75.01 |
| Max. Negotiated Rate |
$96.44 |
| Rate for Payer: Aetna of IA Commercial |
$96.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$96.44
|
| Rate for Payer: Cash Price |
$85.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.37
|
| Rate for Payer: Medical Associates Commercial |
$80.37
|
| Rate for Payer: Midlands Choice Commercial |
$75.01
|
| Rate for Payer: United Healthcare Commercial |
$96.44
|
|
|
TESTOSTERONE FREE
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
8487820
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
|
|
TESTOSTERONE FREE
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
8487820
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$64.35 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Aetna of IA Medicare |
$81.51
|
| Rate for Payer: Amerigroup Medicaid |
$82.48
|
| Rate for Payer: Amerigroup Medicare |
$64.99
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.68
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.35
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$74.00
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.37
|
|
|
TESTOSTERONE FREE
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
8094267
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
|
|
TESTOSTERONE FREE
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
8094267
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$64.35 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Aetna of IA Medicare |
$81.51
|
| Rate for Payer: Amerigroup Medicaid |
$82.48
|
| Rate for Payer: Amerigroup Medicare |
$64.99
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.68
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.35
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$74.00
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.37
|
|
|
Testosterone Total and Free DMCL
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
8037809
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$70.65 |
| Max. Negotiated Rate |
$141.30 |
| Rate for Payer: Aetna of IA Commercial |
$141.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$141.30
|
| Rate for Payer: Aetna of IA Medicare |
$89.49
|
| Rate for Payer: Amerigroup Medicaid |
$90.56
|
| Rate for Payer: Amerigroup Medicare |
$71.36
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$117.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$70.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.68
|
| Rate for Payer: Medical Associates Commercial |
$117.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$70.65
|
| Rate for Payer: Midlands Choice Commercial |
$109.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.25
|
| Rate for Payer: United Healthcare Commercial |
$141.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$92.63
|
|
|
Testosterone Total and Free DMCL
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
8037809
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$109.90 |
| Max. Negotiated Rate |
$141.30 |
| Rate for Payer: Aetna of IA Commercial |
$141.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$141.30
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$117.75
|
| Rate for Payer: Medical Associates Commercial |
$117.75
|
| Rate for Payer: Midlands Choice Commercial |
$109.90
|
| Rate for Payer: United Healthcare Commercial |
$141.30
|
|
|
Testosterone Total DMCL
|
Facility
|
IP
|
$211.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
8037808
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$147.70 |
| Max. Negotiated Rate |
$189.90 |
| Rate for Payer: Aetna of IA Commercial |
$189.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$189.90
|
| Rate for Payer: Cash Price |
$168.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$158.25
|
| Rate for Payer: Medical Associates Commercial |
$158.25
|
| Rate for Payer: Midlands Choice Commercial |
$147.70
|
| Rate for Payer: United Healthcare Commercial |
$189.90
|
|
|
Testosterone Total DMCL
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
8037808
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$94.95 |
| Max. Negotiated Rate |
$189.90 |
| Rate for Payer: Aetna of IA Commercial |
$189.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$189.90
|
| Rate for Payer: Aetna of IA Medicare |
$120.27
|
| Rate for Payer: Amerigroup Medicaid |
$121.70
|
| Rate for Payer: Amerigroup Medicare |
$95.90
|
| Rate for Payer: Cash Price |
$168.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$158.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$94.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$120.52
|
| Rate for Payer: Medical Associates Commercial |
$158.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$94.95
|
| Rate for Payer: Midlands Choice Commercial |
$147.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$122.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.19
|
| Rate for Payer: United Healthcare Commercial |
$189.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$124.49
|
|
|
tetanus-diphtheria toxoids adult IM Susp 0.5 mL [VDMC]
|
Facility
|
IP
|
$88.34
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
10424318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$61.84 |
| Max. Negotiated Rate |
$79.51 |
| Rate for Payer: Aetna of IA Commercial |
$79.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$79.51
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$66.25
|
| Rate for Payer: Medical Associates Commercial |
$66.25
|
| Rate for Payer: Midlands Choice Commercial |
$61.84
|
| Rate for Payer: United Healthcare Commercial |
$79.51
|
|
|
tetanus-diphtheria toxoids adult IM Susp 0.5 mL [VDMC]
|
Facility
|
OP
|
$88.34
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
10424318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.75 |
| Max. Negotiated Rate |
$79.51 |
| Rate for Payer: Aetna of IA Commercial |
$79.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$79.51
|
| Rate for Payer: Aetna of IA Medicare |
$50.35
|
| Rate for Payer: Amerigroup Medicaid |
$50.95
|
| Rate for Payer: Amerigroup Medicare |
$40.15
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$66.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$39.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$50.46
|
| Rate for Payer: Medical Associates Commercial |
$66.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$39.75
|
| Rate for Payer: Midlands Choice Commercial |
$61.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$51.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.72
|
| Rate for Payer: United Healthcare Commercial |
$79.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$52.12
|
|
|
tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2.5 units-18.5 mcg/0.5 mL Sus [VDMC]
|
Facility
|
IP
|
$90.45
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
21188189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.31 |
| Max. Negotiated Rate |
$81.40 |
| Rate for Payer: Aetna of IA Commercial |
$81.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$81.40
|
| Rate for Payer: Cash Price |
$72.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$67.83
|
| Rate for Payer: Medical Associates Commercial |
$67.83
|
| Rate for Payer: Midlands Choice Commercial |
$63.31
|
| Rate for Payer: United Healthcare Commercial |
$81.40
|
|
|
tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2.5 units-18.5 mcg/0.5 mL Sus [VDMC]
|
Facility
|
OP
|
$90.45
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
21188189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.70 |
| Max. Negotiated Rate |
$81.40 |
| Rate for Payer: Aetna of IA Commercial |
$81.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$81.40
|
| Rate for Payer: Aetna of IA Medicare |
$51.55
|
| Rate for Payer: Amerigroup Medicaid |
$52.17
|
| Rate for Payer: Amerigroup Medicare |
$41.11
|
| Rate for Payer: Cash Price |
$72.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$67.83
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$40.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$51.66
|
| Rate for Payer: Medical Associates Commercial |
$67.83
|
| Rate for Payer: Medical Associates Managed Medicare |
$40.70
|
| Rate for Payer: Midlands Choice Commercial |
$63.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$52.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$46.81
|
| Rate for Payer: United Healthcare Commercial |
$81.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$53.36
|
|
|
tetanus-diphth toxoids (Td) adult/adol 2 units-2 units/0.5 mL Sus[VDMC]
|
Facility
|
OP
|
$64.91
|
|
|
Service Code
|
HCPCS 90414
|
| Hospital Charge Code |
12698337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$58.42 |
| Rate for Payer: Aetna of IA Commercial |
$58.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.42
|
| Rate for Payer: Aetna of IA Medicare |
$37.00
|
| Rate for Payer: Amerigroup Medicaid |
$37.44
|
| Rate for Payer: Amerigroup Medicare |
$29.50
|
| Rate for Payer: Cash Price |
$51.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.08
|
| Rate for Payer: Medical Associates Commercial |
$48.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.21
|
| Rate for Payer: Midlands Choice Commercial |
$45.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.59
|
| Rate for Payer: United Healthcare Commercial |
$58.42
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.30
|
|
|
tetanus-diphth toxoids (Td) adult/adol 2 units-2 units/0.5 mL Sus[VDMC]
|
Facility
|
IP
|
$64.91
|
|
|
Service Code
|
HCPCS 90414
|
| Hospital Charge Code |
12698337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.44 |
| Max. Negotiated Rate |
$58.42 |
| Rate for Payer: Aetna of IA Commercial |
$58.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.42
|
| Rate for Payer: Cash Price |
$51.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.68
|
| Rate for Payer: Medical Associates Commercial |
$48.68
|
| Rate for Payer: Midlands Choice Commercial |
$45.44
|
| Rate for Payer: United Healthcare Commercial |
$58.42
|
|
|
tetanus immune globulin 250 units IM SD Sol 1 EA [VDMC]
|
Facility
|
IP
|
$942.00
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
10424180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$659.40 |
| Max. Negotiated Rate |
$847.80 |
| Rate for Payer: Aetna of IA Commercial |
$847.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$847.80
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$706.50
|
| Rate for Payer: Medical Associates Commercial |
$706.50
|
| Rate for Payer: Midlands Choice Commercial |
$659.40
|
| Rate for Payer: United Healthcare Commercial |
$847.80
|
|
