|
Tendonitis, Myositis and Bursitis With MCC
|
Facility
IP
|
$8,619.99
|
|
|
Service Code
|
MS-DRG 557
|
| Hospital Charge Code |
364
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$8,619.99 |
| Rate for Payer: Amerigroup Medicaid |
$8,578.34
|
| 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 |
$8,495.06
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,619.99
|
|
|
Tendonitis, Myositis and Bursitis Without MCC
|
Facility
IP
|
$6,202.69
|
|
|
Service Code
|
MS-DRG 558
|
| Hospital Charge Code |
365
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$6,202.69 |
| Rate for Payer: Amerigroup Medicaid |
$6,172.73
|
| 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 |
$6,112.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,202.69
|
|
|
tenecteplase 50 mg IV SDV Inj
|
Facility
IP
|
$14,118.70
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701592
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9,883.09 |
| Max. Negotiated Rate |
$12,706.83 |
| Rate for Payer: Aetna of IA Commercial |
$12,706.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12,706.83
|
| Rate for Payer: Cash Price |
$11,294.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10,589.02
|
| Rate for Payer: Medical Associates Commercial |
$10,589.02
|
| Rate for Payer: Midlands Choice Commercial |
$9,883.09
|
| Rate for Payer: United Healthcare Commercial |
$12,706.83
|
|
|
tenecteplase 50 mg IV SDV Inj
|
Facility
OP
|
$14,118.70
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701592
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,056.53 |
| Max. Negotiated Rate |
$12,706.83 |
| Rate for Payer: Aetna of IA Commercial |
$12,706.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12,706.83
|
| Rate for Payer: Aetna of IA Medicare |
$8,047.66
|
| Rate for Payer: Amerigroup Medicaid |
$7,125.71
|
| Rate for Payer: Amerigroup Medicare |
$7,129.94
|
| Rate for Payer: Cash Price |
$11,294.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10,589.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7,059.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7,056.53
|
| Rate for Payer: Medical Associates Commercial |
$10,589.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$7,059.35
|
| Rate for Payer: Midlands Choice Commercial |
$9,883.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,165.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$10,589.02
|
| Rate for Payer: United Healthcare Commercial |
$12,706.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$8,330.03
|
|
|
terazosin 1 mg Cap
|
Facility
OP
|
$1.46
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701596
|
|
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
|
|
|
terazosin 1 mg Cap
|
Facility
IP
|
$1.46
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701596
|
|
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
|
|
|
terazosin 5 mg Cap
|
Facility
OP
|
$1.49
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of IA Commercial |
$1.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.34
|
| Rate for Payer: Aetna of IA Medicare |
$0.85
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.75
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.74
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.75
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.88
|
|
|
terazosin 5 mg Cap
|
Facility
IP
|
$1.49
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of IA Commercial |
$1.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.34
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: United Healthcare Commercial |
$1.34
|
|
|
terbinafine 250 mg Tab
|
Facility
OP
|
$2.07
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43791237
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of IA Commercial |
$1.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.86
|
| Rate for Payer: Aetna of IA Medicare |
$1.18
|
| Rate for Payer: Amerigroup Medicaid |
$1.04
|
| Rate for Payer: Amerigroup Medicare |
$1.05
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.55
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.03
|
| Rate for Payer: Medical Associates Commercial |
$1.55
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.04
|
| Rate for Payer: Midlands Choice Commercial |
$1.45
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.22
|
|
|
terbinafine 250 mg Tab
|
Facility
IP
|
$2.07
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43791237
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of IA Commercial |
$1.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.86
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.55
|
| Rate for Payer: Medical Associates Commercial |
$1.55
|
| Rate for Payer: Midlands Choice Commercial |
$1.45
|
| Rate for Payer: United Healthcare Commercial |
$1.86
|
|
|
terbinafine topical 1% Cre 15gm
|
Facility
OP
|
$33.12
|
|
|
Service Code
|
CPT J3105
|
| Hospital Charge Code |
43701276
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.55 |
| 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 |
$16.72
|
| Rate for Payer: Amerigroup Medicare |
$16.73
|
| 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 |
$16.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.55
|
| Rate for Payer: Medical Associates Commercial |
$24.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.56
|
| Rate for Payer: Midlands Choice Commercial |
$23.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.84
|
| Rate for Payer: United Healthcare Commercial |
$29.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.54
|
|
|
terbinafine topical 1% Cre 15gm
|
Facility
IP
|
$33.12
|
|
|
Service Code
|
CPT J3105
|
| Hospital Charge Code |
43701276
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
terbutaline 1 mg/mL 1 ml Inj SDV
|
Facility
IP
|
$25.41
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700464
|
|
Hospital Revenue Code
|
636
|
| 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
|
Facility
OP
|
$25.41
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.70 |
| 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 |
$12.82
|
| Rate for Payer: Amerigroup Medicare |
$12.83
|
| 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 |
$12.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.70
|
| Rate for Payer: Medical Associates Commercial |
$19.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.70
|
| Rate for Payer: Midlands Choice Commercial |
$17.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.06
|
| Rate for Payer: United Healthcare Commercial |
$22.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.99
|
|
|
Testes Procedures With CC/MCC
|
Facility
IP
|
$20,972.22
|
|
|
Service Code
|
MS-DRG 711
|
| Hospital Charge Code |
478
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$20,972.22 |
| Rate for Payer: Amerigroup Medicaid |
$20,870.90
|
| 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 |
$20,668.27
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20,972.22
|
|
|
Testes Procedures Without CC/MCC
|
Facility
IP
|
$8,586.53
|
|
|
Service Code
|
MS-DRG 712
|
| Hospital Charge Code |
479
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$8,586.53 |
| Rate for Payer: Amerigroup Medicaid |
$8,545.04
|
| 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 |
$8,462.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,586.53
|
|
|
TEST IMPLANT
|
Facility
OP
|
$1,000.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8753463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$499.80 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna of IA Medicare |
$570.00
|
| Rate for Payer: Aetna of IA Commercial |
$900.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$900.00
|
| Rate for Payer: Amerigroup Medicaid |
$504.70
|
| Rate for Payer: Amerigroup Medicare |
$505.00
|
| 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 |
$500.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$499.80
|
| Rate for Payer: Medical Associates Commercial |
$750.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$500.00
|
| Rate for Payer: Midlands Choice Commercial |
$700.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$507.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$750.00
|
| Rate for Payer: United Healthcare Commercial |
$900.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$590.00
|
|
|
TEST IMPLANT
|
Facility
IP
|
$1,000.00
|
|
|
Service Code
|
CPT 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
|
|
|
testosterone 75 mg Imp
|
Facility
OP
|
$351.28
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
43702084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$175.57 |
| Max. Negotiated Rate |
$316.15 |
| Rate for Payer: Aetna of IA Commercial |
$316.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$316.15
|
| Rate for Payer: Aetna of IA Medicare |
$200.23
|
| Rate for Payer: Amerigroup Medicaid |
$177.29
|
| Rate for Payer: Amerigroup Medicare |
$177.40
|
| 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 |
$175.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$175.57
|
| Rate for Payer: Medical Associates Commercial |
$263.46
|
| Rate for Payer: Medical Associates Managed Medicare |
$175.64
|
| Rate for Payer: Midlands Choice Commercial |
$245.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$178.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$263.46
|
| Rate for Payer: United Healthcare Commercial |
$316.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$207.26
|
|
|
testosterone 75 mg Imp
|
Facility
IP
|
$351.28
|
|
|
Service Code
|
CPT J1071
|
| Hospital Charge Code |
43702084
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$245.90 |
| Max. Negotiated Rate |
$316.15 |
| Rate for Payer: Aetna of IA Commercial |
$316.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$316.15
|
| 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 |
$316.15
|
|
|
testosterone cypionate 200 mg/mL 1 ml IM SDV
|
Facility
OP
|
$77.60
|
|
|
Service Code
|
CPT J1670
|
| Hospital Charge Code |
43701834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.78 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: Aetna of IA Commercial |
$69.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.84
|
| Rate for Payer: Aetna of IA Medicare |
$44.23
|
| Rate for Payer: Amerigroup Medicaid |
$39.16
|
| Rate for Payer: Amerigroup Medicare |
$39.19
|
| Rate for Payer: Cash Price |
$62.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$38.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.78
|
| Rate for Payer: Medical Associates Commercial |
$58.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$38.80
|
| Rate for Payer: Midlands Choice Commercial |
$54.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$39.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$58.20
|
| Rate for Payer: United Healthcare Commercial |
$69.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$45.78
|
|
|
testosterone cypionate 200 mg/mL 1 ml IM SDV
|
Facility
IP
|
$77.60
|
|
|
Service Code
|
CPT J1670
|
| Hospital Charge Code |
43701834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: Aetna of IA Commercial |
$69.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.84
|
| Rate for Payer: Cash Price |
$62.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.20
|
| Rate for Payer: Medical Associates Commercial |
$58.20
|
| Rate for Payer: Midlands Choice Commercial |
$54.32
|
| Rate for Payer: United Healthcare Commercial |
$69.84
|
|
|
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 |
$47.12 |
| 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 |
$72.17
|
| Rate for Payer: Amerigroup Medicare |
$72.22
|
| Rate for Payer: Cash Price |
$114.40
|
| 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 |
$71.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$71.47
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$71.50
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$72.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$107.25
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.37
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
TESTOSTERONE FREE
|
Facility
OP
|
$143.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
8094267
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| 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 |
$72.17
|
| Rate for Payer: Amerigroup Medicare |
$72.22
|
| Rate for Payer: Cash Price |
$114.40
|
| 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 |
$71.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$71.47
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$71.50
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$72.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$107.25
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.37
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
