|
T3 Reverse DMCL
|
Facility
OP
|
$129.00
|
|
|
Service Code
|
CPT 84482
|
| Hospital Charge Code |
8037805
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Aetna of IA Medicare |
$73.53
|
| Rate for Payer: Amerigroup Medicaid |
$65.11
|
| Rate for Payer: Amerigroup Medicare |
$65.14
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$64.47
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.50
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$65.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$96.75
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
T3 Total DMCL
|
Facility
OP
|
$104.00
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
8037806
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Aetna of IA Medicare |
$59.28
|
| Rate for Payer: Amerigroup Medicaid |
$52.49
|
| Rate for Payer: Amerigroup Medicare |
$52.52
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$52.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$51.98
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$52.00
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$52.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$78.00
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.36
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
T3 Total DMCL
|
Facility
IP
|
$104.00
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
8037806
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
|
|
T4
|
Facility
OP
|
$65.00
|
|
|
Service Code
|
CPT 84436
|
| Hospital Charge Code |
7928767
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.49 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Aetna of IA Medicare |
$37.05
|
| Rate for Payer: Amerigroup Medicaid |
$32.81
|
| Rate for Payer: Amerigroup Medicare |
$32.82
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.49
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.50
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$48.75
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.35
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
T4
|
Facility
IP
|
$65.00
|
|
|
Service Code
|
CPT 84436
|
| Hospital Charge Code |
7928767
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
|
|
T4 FREE
|
Facility
IP
|
$82.00
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
4021360
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
|
|
T4 FREE
|
Facility
OP
|
$82.00
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
4021360
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.98 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Aetna of IA Medicare |
$46.74
|
| Rate for Payer: Amerigroup Medicaid |
$41.39
|
| Rate for Payer: Amerigroup Medicare |
$41.41
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$41.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40.98
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$41.00
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.50
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.38
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
TA 45 3.5MM LOAD
|
Facility
IP
|
$119.00
|
|
| Hospital Charge Code |
8026284
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
TA 45 3.5MM LOAD
|
Facility
OP
|
$119.00
|
|
| Hospital Charge Code |
8026284
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.48 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
TA 45 3.5MM STAPLER
|
Facility
IP
|
$477.00
|
|
| Hospital Charge Code |
8026072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$333.90 |
| Max. Negotiated Rate |
$429.30 |
| Rate for Payer: Aetna of IA Commercial |
$429.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$429.30
|
| Rate for Payer: Cash Price |
$381.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$357.75
|
| Rate for Payer: Medical Associates Commercial |
$357.75
|
| Rate for Payer: Midlands Choice Commercial |
$333.90
|
| Rate for Payer: United Healthcare Commercial |
$429.30
|
|
|
TA 45 3.5MM STAPLER
|
Facility
OP
|
$477.00
|
|
| Hospital Charge Code |
8026072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.40 |
| Max. Negotiated Rate |
$429.30 |
| Rate for Payer: Aetna of IA Commercial |
$429.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$429.30
|
| Rate for Payer: Aetna of IA Medicare |
$271.89
|
| Rate for Payer: Amerigroup Medicaid |
$240.74
|
| Rate for Payer: Amerigroup Medicare |
$240.88
|
| Rate for Payer: Cash Price |
$381.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$357.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$238.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$238.40
|
| Rate for Payer: Medical Associates Commercial |
$357.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$238.50
|
| Rate for Payer: Midlands Choice Commercial |
$333.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$242.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$357.75
|
| Rate for Payer: United Healthcare Commercial |
$429.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$281.43
|
|
|
tacrolimus 0.5 mg Oral Cap
|
Facility
OP
|
$1.55
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Aetna of IA Commercial |
$1.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.40
|
| Rate for Payer: Aetna of IA Medicare |
$0.88
|
| Rate for Payer: Amerigroup Medicaid |
$0.78
|
| Rate for Payer: Amerigroup Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.77
|
| Rate for Payer: Medical Associates Commercial |
$1.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.78
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.91
|
|
|
tacrolimus 0.5 mg Oral Cap
|
Facility
IP
|
$1.55
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Aetna of IA Commercial |
$1.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.40
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.16
|
| Rate for Payer: Medical Associates Commercial |
$1.16
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
|
|
Tacrolimus Level DMCL
|
Facility
IP
|
$150.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
8037807
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
|
|
Tacrolimus Level DMCL
|
Facility
OP
|
$150.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
8037807
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Aetna of IA Medicare |
$85.50
|
| Rate for Payer: Amerigroup Medicaid |
$75.70
|
| Rate for Payer: Amerigroup Medicare |
$75.75
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.97
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.00
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.50
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$88.50
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
tadalafil 5 mg Tab
|
Facility
OP
|
$1.22
|
|
|
Service Code
|
CPT J9349
|
| Hospital Charge Code |
43701093
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Aetna of IA Medicare |
$0.70
|
| Rate for Payer: Amerigroup Medicaid |
$0.62
|
| Rate for Payer: Amerigroup Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.61
|
| Rate for Payer: Medical Associates Commercial |
$0.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.61
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.72
|
|
|
tadalafil 5 mg Tab
|
Facility
IP
|
$1.22
|
|
|
Service Code
|
CPT J9349
|
| Hospital Charge Code |
43701093
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.92
|
| Rate for Payer: Medical Associates Commercial |
$0.92
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
|
|
tafasitamab-CXIX 200 mg Pow SDV
|
Facility
IP
|
$2,756.56
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702014
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,929.59 |
| Max. Negotiated Rate |
$2,480.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,480.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,480.90
|
| Rate for Payer: Cash Price |
$2,205.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,067.42
|
| Rate for Payer: Medical Associates Commercial |
$2,067.42
|
| Rate for Payer: Midlands Choice Commercial |
$1,929.59
|
| Rate for Payer: United Healthcare Commercial |
$2,480.90
|
|
|
tafasitamab-CXIX 200 mg Pow SDV
|
Facility
OP
|
$2,756.56
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702014
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,377.73 |
| Max. Negotiated Rate |
$2,480.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,480.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,480.90
|
| Rate for Payer: Aetna of IA Medicare |
$1,571.24
|
| Rate for Payer: Amerigroup Medicaid |
$1,391.24
|
| Rate for Payer: Amerigroup Medicare |
$1,392.06
|
| Rate for Payer: Cash Price |
$2,205.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,067.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,378.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,377.73
|
| Rate for Payer: Medical Associates Commercial |
$2,067.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,378.28
|
| Rate for Payer: Midlands Choice Commercial |
$1,929.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,398.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,067.42
|
| Rate for Payer: United Healthcare Commercial |
$2,480.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,626.37
|
|
|
TALAR DOME LARGE
|
Facility
IP
|
$3,330.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8831373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,331.00 |
| Max. Negotiated Rate |
$2,997.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,997.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,997.00
|
| Rate for Payer: Cash Price |
$2,664.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,497.50
|
| Rate for Payer: Medical Associates Commercial |
$2,497.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,331.00
|
| Rate for Payer: United Healthcare Commercial |
$2,997.00
|
|
|
TALAR DOME LARGE
|
Facility
OP
|
$3,330.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8831373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,664.33 |
| Max. Negotiated Rate |
$2,997.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,997.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,997.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,898.10
|
| Rate for Payer: Amerigroup Medicaid |
$1,680.65
|
| Rate for Payer: Amerigroup Medicare |
$1,681.65
|
| Rate for Payer: Cash Price |
$2,664.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,497.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,665.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,664.33
|
| Rate for Payer: Medical Associates Commercial |
$2,497.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,665.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,331.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,689.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,497.50
|
| Rate for Payer: United Healthcare Commercial |
$2,997.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,964.70
|
|
|
TALAR DOME MEDIUM
|
Facility
IP
|
$2,691.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783238
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,883.70 |
| Max. Negotiated Rate |
$2,421.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,421.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,421.90
|
| Rate for Payer: Cash Price |
$2,152.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,018.25
|
| Rate for Payer: Medical Associates Commercial |
$2,018.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,883.70
|
| Rate for Payer: United Healthcare Commercial |
$2,421.90
|
|
|
TALAR DOME MEDIUM
|
Facility
OP
|
$2,691.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783238
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,344.96 |
| Max. Negotiated Rate |
$2,421.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,421.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,421.90
|
| Rate for Payer: Aetna of IA Medicare |
$1,533.87
|
| Rate for Payer: Amerigroup Medicaid |
$1,358.15
|
| Rate for Payer: Amerigroup Medicare |
$1,358.96
|
| Rate for Payer: Cash Price |
$2,152.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,018.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,345.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,344.96
|
| Rate for Payer: Medical Associates Commercial |
$2,018.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,345.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,883.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,365.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,018.25
|
| Rate for Payer: United Healthcare Commercial |
$2,421.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,587.69
|
|
|
tamoxifen 10 mg Tab
|
Facility
IP
|
$1.46
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna of IA Commercial |
$1.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.31
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.10
|
| Rate for Payer: Medical Associates Commercial |
$1.10
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
|
|
tamoxifen 10 mg Tab
|
Facility
OP
|
$1.46
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna of IA Commercial |
$1.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.31
|
| Rate for Payer: Aetna of IA Medicare |
$0.83
|
| Rate for Payer: Amerigroup Medicaid |
$0.74
|
| Rate for Payer: Amerigroup Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.73
|
| Rate for Payer: Medical Associates Commercial |
$1.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.73
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.86
|
|
