|
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 TOTAL
|
Facility
OP
|
$142.00
|
|
|
Service Code
|
CPT 84410
|
| Hospital Charge Code |
8037810
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$70.97 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna of IA Commercial |
$127.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.80
|
| Rate for Payer: Aetna of IA Medicare |
$80.94
|
| Rate for Payer: Amerigroup Medicaid |
$71.67
|
| Rate for Payer: Amerigroup Medicare |
$71.71
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$71.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$70.97
|
| Rate for Payer: Medical Associates Commercial |
$106.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$71.00
|
| Rate for Payer: Midlands Choice Commercial |
$99.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$72.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$106.50
|
| Rate for Payer: United Healthcare Commercial |
$127.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$83.78
|
| Rate for Payer: Wellmark IA HMO |
$85.56
|
| Rate for Payer: Wellmark IA PPO |
$94.12
|
|
|
TESTOSTERONE TOTAL
|
Facility
IP
|
$142.00
|
|
|
Service Code
|
CPT 84410
|
| Hospital Charge Code |
8037810
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna of IA Commercial |
$127.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.80
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.50
|
| Rate for Payer: Medical Associates Commercial |
$106.50
|
| Rate for Payer: Midlands Choice Commercial |
$99.40
|
| Rate for Payer: United Healthcare Commercial |
$127.80
|
|
|
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 and Free DMCL
|
Facility
OP
|
$157.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
8037809
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| 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 |
$79.24
|
| Rate for Payer: Amerigroup Medicare |
$79.28
|
| Rate for Payer: Cash Price |
$125.60
|
| 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 |
$78.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$78.47
|
| Rate for Payer: Medical Associates Commercial |
$117.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$78.50
|
| Rate for Payer: Midlands Choice Commercial |
$109.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$79.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$117.75
|
| Rate for Payer: United Healthcare Commercial |
$141.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$92.63
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
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 |
$47.12 |
| 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 |
$106.49
|
| Rate for Payer: Amerigroup Medicare |
$106.56
|
| Rate for Payer: Cash Price |
$168.80
|
| 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 |
$105.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$105.46
|
| Rate for Payer: Medical Associates Commercial |
$158.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$105.50
|
| Rate for Payer: Midlands Choice Commercial |
$147.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$107.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$158.25
|
| Rate for Payer: United Healthcare Commercial |
$189.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$124.49
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
tetanus-diphth toxoids (Td) adult/adol 2 units-2 units/0.5 mL Sus
|
Facility
OP
|
$64.91
|
|
|
Service Code
|
NDC 13533-0131-01
|
| Hospital Charge Code |
43700477
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.44 |
| 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: Aetna of IA Medicare |
$37.00
|
| Rate for Payer: Amerigroup Medicaid |
$32.76
|
| Rate for Payer: Amerigroup Medicare |
$32.78
|
| 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 |
$32.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.44
|
| Rate for Payer: Medical Associates Commercial |
$48.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.46
|
| Rate for Payer: Midlands Choice Commercial |
$45.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$48.68
|
| 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
|
Facility
IP
|
$64.91
|
|
|
Service Code
|
NDC 13533-0131-01
|
| Hospital Charge Code |
43700477
|
|
Hospital Revenue Code
|
636
|
| 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
|
Facility
IP
|
$942.00
|
|
|
Service Code
|
CPT 90414
|
| Hospital Charge Code |
43700477
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
tetanus immune globulin 250 units IM SD Sol 1 EA
|
Facility
OP
|
$942.00
|
|
|
Service Code
|
CPT 90414
|
| Hospital Charge Code |
43700477
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$470.81 |
| 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: Aetna of IA Medicare |
$536.94
|
| Rate for Payer: Amerigroup Medicaid |
$475.43
|
| Rate for Payer: Amerigroup Medicare |
$475.71
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$706.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$471.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$470.81
|
| Rate for Payer: Medical Associates Commercial |
$706.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$471.00
|
| Rate for Payer: Midlands Choice Commercial |
$659.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$478.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$706.50
|
| Rate for Payer: United Healthcare Commercial |
$847.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$555.78
|
|
|
Thawing Fee
|
Facility
IP
|
$52.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
8018868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
|
|
Thawing Fee
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
8018868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$60.70 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Aetna of IA Medicare |
$29.64
|
| Rate for Payer: Amerigroup Medicaid |
$26.24
|
| Rate for Payer: Amerigroup Medicare |
$26.26
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$25.99
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.00
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.00
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.68
|
| Rate for Payer: Wellmark IA HMO |
$55.18
|
| Rate for Payer: Wellmark IA PPO |
$60.70
|
|
|
theophylline 100 mg/24 hours ER Cap
|
Facility
OP
|
$12.79
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702464
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.39 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna of IA Commercial |
$11.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.51
|
| Rate for Payer: Aetna of IA Medicare |
$7.29
|
| Rate for Payer: Amerigroup Medicaid |
$6.46
|
| Rate for Payer: Amerigroup Medicare |
$6.46
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.59
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.39
|
| Rate for Payer: Medical Associates Commercial |
$9.59
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.40
|
| Rate for Payer: Midlands Choice Commercial |
$8.95
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.59
|
| Rate for Payer: United Healthcare Commercial |
$11.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.55
|
|
|
theophylline 100 mg/24 hours ER Cap
|
Facility
OP
|
$12.79
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.39 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna of IA Commercial |
$11.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.51
|
| Rate for Payer: Aetna of IA Medicare |
$7.29
|
| Rate for Payer: Amerigroup Medicaid |
$6.46
|
| Rate for Payer: Amerigroup Medicare |
$6.46
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.59
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.39
|
| Rate for Payer: Medical Associates Commercial |
$9.59
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.40
|
| Rate for Payer: Midlands Choice Commercial |
$8.95
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.59
|
| Rate for Payer: United Healthcare Commercial |
$11.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.55
|
|
|
theophylline 100 mg/24 hours ER Cap
|
Facility
IP
|
$12.79
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna of IA Commercial |
$11.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.51
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.59
|
| Rate for Payer: Medical Associates Commercial |
$9.59
|
| Rate for Payer: Midlands Choice Commercial |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$11.51
|
|
|
theophylline 100 mg/24 hours ER Cap
|
Facility
IP
|
$12.79
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702464
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna of IA Commercial |
$11.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.51
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.59
|
| Rate for Payer: Medical Associates Commercial |
$9.59
|
| Rate for Payer: Midlands Choice Commercial |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$11.51
|
|
|
Theophylline DMCL
|
Facility
IP
|
$96.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
8037811
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of IA Commercial |
$86.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.40
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.00
|
| Rate for Payer: Medical Associates Commercial |
$72.00
|
| Rate for Payer: Midlands Choice Commercial |
$67.20
|
| Rate for Payer: United Healthcare Commercial |
$86.40
|
|
|
Theophylline DMCL
|
Facility
OP
|
$96.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
8037811
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.98 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of IA Commercial |
$86.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.40
|
| Rate for Payer: Aetna of IA Medicare |
$54.72
|
| Rate for Payer: Amerigroup Medicaid |
$48.45
|
| Rate for Payer: Amerigroup Medicare |
$48.48
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$48.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$47.98
|
| Rate for Payer: Medical Associates Commercial |
$72.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$48.00
|
| Rate for Payer: Midlands Choice Commercial |
$67.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$48.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$72.00
|
| Rate for Payer: United Healthcare Commercial |
$86.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$56.64
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
THERA ACTIVITIES 15 MIN, DIRECT
|
Facility
IP
|
$109.00
|
|
|
Service Code
|
CPT 97530 GP
|
| Hospital Charge Code |
1374031
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
|
|
THERA ACTIVITIES 15 MIN, DIRECT
|
Facility
OP
|
$109.00
|
|
|
Service Code
|
CPT 97530 GP
|
| Hospital Charge Code |
1374031
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$54.48 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Aetna of IA Medicare |
$62.13
|
| Rate for Payer: Amerigroup Medicaid |
$55.01
|
| Rate for Payer: Amerigroup Medicare |
$55.04
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$54.48
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.50
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$55.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.75
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.31
|
|
|
THER ACTIVITIES DIRECT PER 15 MIN
|
Facility
OP
|
$109.00
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
1373450
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$54.48 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Aetna of IA Medicare |
$62.13
|
| Rate for Payer: Amerigroup Medicaid |
$55.01
|
| Rate for Payer: Amerigroup Medicare |
$55.04
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$54.48
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.50
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$55.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.75
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.31
|
|
|
THER ACTIVITIES DIRECT PER 15 MIN
|
Facility
IP
|
$109.00
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
1373450
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
|
|
THER ACTIVITY DIRECT 15 MIN
|
Facility
OP
|
$181.00
|
|
|
Service Code
|
CPT 97530 GN
|
| Hospital Charge Code |
752354
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$90.46 |
| Max. Negotiated Rate |
$162.90 |
| Rate for Payer: Aetna of IA Commercial |
$162.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.90
|
| Rate for Payer: Aetna of IA Medicare |
$103.17
|
| Rate for Payer: Amerigroup Medicaid |
$91.35
|
| Rate for Payer: Amerigroup Medicare |
$91.40
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$90.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$90.46
|
| Rate for Payer: Medical Associates Commercial |
$135.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.50
|
| Rate for Payer: Midlands Choice Commercial |
$126.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$135.75
|
| Rate for Payer: United Healthcare Commercial |
$162.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.79
|
|
|
THER ACTIVITY DIRECT 15 MIN
|
Facility
IP
|
$181.00
|
|
|
Service Code
|
CPT 97530 GN
|
| Hospital Charge Code |
752354
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$126.70 |
| Max. Negotiated Rate |
$162.90 |
| Rate for Payer: Aetna of IA Commercial |
$162.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.90
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.75
|
| Rate for Payer: Medical Associates Commercial |
$135.75
|
| Rate for Payer: Midlands Choice Commercial |
$126.70
|
| Rate for Payer: United Healthcare Commercial |
$162.90
|
|
