|
tacrolimus 0.5 mg Oral Cap [VDMC]
|
Facility
|
IP
|
$1.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423212
|
|
Hospital Revenue Code
|
259
|
| 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 0.5 mg Oral Cap [VDMC]
|
Facility
|
OP
|
$1.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423212
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$0.79
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.16
|
| 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 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: Molina Healthcare Managed Medicare |
$76.08
|
| Rate for Payer: Oscar Health of IA Commercial |
$112.50
|
| 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
|
|
|
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
|
|
|
tadalafil 5 mg Tab [VDMC]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423354
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$0.62
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.92
|
| 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 [VDMC]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423354
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$2,756.56
|
|
|
Service Code
|
HCPCS J9349
|
| Hospital Charge Code |
23872251
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$1,398.13
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,067.42
|
| 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
|
|
|
tafasitamab-CXIX 200 mg Pow SDV [VDMC]
|
Facility
|
IP
|
$2,756.56
|
|
|
Service Code
|
HCPCS J9349
|
| Hospital Charge Code |
23872251
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
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: Molina Healthcare Managed Medicare |
$1,688.98
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,497.50
|
| 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
|
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: Molina Healthcare Managed Medicare |
$1,364.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,018.25
|
| 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
|
|
|
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
|
|
|
tamoxifen 10 mg Tab [VDMC]
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423425
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$0.74
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.10
|
| 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
|
|
|
tamoxifen 10 mg Tab [VDMC]
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423425
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
tamsulosin 0.4 mg Oral Cap [VDMC]
|
Facility
|
IP
|
$1.73
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423496
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of IA Commercial |
$1.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.56
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.30
|
| Rate for Payer: Medical Associates Commercial |
$1.30
|
| Rate for Payer: Midlands Choice Commercial |
$1.21
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
|
|
tamsulosin 0.4 mg Oral Cap [VDMC]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423496
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of IA Commercial |
$1.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.56
|
| Rate for Payer: Aetna of IA Medicare |
$0.99
|
| Rate for Payer: Amerigroup Medicaid |
$0.87
|
| Rate for Payer: Amerigroup Medicare |
$0.87
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.86
|
| Rate for Payer: Medical Associates Commercial |
$1.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.87
|
| Rate for Payer: Midlands Choice Commercial |
$1.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.02
|
|
|
TAP CANCELLOUS BONE SCREW 3.5MM
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$277.20 |
| Max. Negotiated Rate |
$356.40 |
| Rate for Payer: Aetna of IA Commercial |
$356.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$356.40
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$297.00
|
| Rate for Payer: Medical Associates Commercial |
$297.00
|
| Rate for Payer: Midlands Choice Commercial |
$277.20
|
| Rate for Payer: United Healthcare Commercial |
$356.40
|
|
|
TAP CANCELLOUS BONE SCREW 3.5MM
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$197.92 |
| Max. Negotiated Rate |
$356.40 |
| Rate for Payer: Aetna of IA Commercial |
$356.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$356.40
|
| Rate for Payer: Aetna of IA Medicare |
$225.72
|
| Rate for Payer: Amerigroup Medicaid |
$199.86
|
| Rate for Payer: Amerigroup Medicare |
$199.98
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$297.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$198.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$197.92
|
| Rate for Payer: Medical Associates Commercial |
$297.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$198.00
|
| Rate for Payer: Midlands Choice Commercial |
$277.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$200.97
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$200.85
|
| Rate for Payer: Oscar Health of IA Commercial |
$297.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$297.00
|
| Rate for Payer: United Healthcare Commercial |
$356.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$233.64
|
|
|
tbo-filgrastim 300 mcg/0.5 mL SD Syringe Sol [VDMC]
|
Facility
|
IP
|
$343.50
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
13501100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$240.45 |
| Max. Negotiated Rate |
$309.15 |
| Rate for Payer: Aetna of IA Commercial |
$309.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$309.15
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$257.62
|
| Rate for Payer: Medical Associates Commercial |
$257.62
|
| Rate for Payer: Midlands Choice Commercial |
$240.45
|
| Rate for Payer: United Healthcare Commercial |
$309.15
|
|
|
tbo-filgrastim 300 mcg/0.5 mL SD Syringe Sol [VDMC]
|
Facility
|
OP
|
$343.50
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
13501100
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$171.68 |
| Max. Negotiated Rate |
$309.15 |
| Rate for Payer: Aetna of IA Commercial |
$309.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$309.15
|
| Rate for Payer: Aetna of IA Medicare |
$195.80
|
| Rate for Payer: Amerigroup Medicaid |
$173.36
|
| Rate for Payer: Amerigroup Medicare |
$173.47
|
| Rate for Payer: Cash Price |
$274.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$257.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$171.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$171.68
|
| Rate for Payer: Medical Associates Commercial |
$257.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$171.75
|
| Rate for Payer: Midlands Choice Commercial |
$240.45
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$174.33
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$174.22
|
| Rate for Payer: Oscar Health of IA Commercial |
$257.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$257.62
|
| Rate for Payer: United Healthcare Commercial |
$309.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$202.66
|
|
|
TCOM/SPP - COMPLETE 2-3 LEVELS
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 93923
|
| Hospital Charge Code |
8013709
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$266.00 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna of IA Commercial |
$342.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.00
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.00
|
| Rate for Payer: Medical Associates Commercial |
$285.00
|
| Rate for Payer: Midlands Choice Commercial |
$266.00
|
| Rate for Payer: United Healthcare Commercial |
$342.00
|
|
|
TCOM/SPP - COMPLETE 2-3 LEVELS
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
CPT 93923
|
| Hospital Charge Code |
8013709
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$189.92 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna of IA Commercial |
$342.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.00
|
| Rate for Payer: Aetna of IA Medicare |
$216.60
|
| Rate for Payer: Amerigroup Medicaid |
$191.79
|
| Rate for Payer: Amerigroup Medicare |
$191.90
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$190.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$189.92
|
| Rate for Payer: Medical Associates Commercial |
$285.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$190.00
|
| Rate for Payer: Midlands Choice Commercial |
$266.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$192.85
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$192.74
|
| Rate for Payer: Oscar Health of IA Commercial |
$285.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$285.00
|
| Rate for Payer: United Healthcare Commercial |
$342.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$224.20
|
| Rate for Payer: Wellmark IA HMO |
$281.48
|
| Rate for Payer: Wellmark IA PPO |
$309.63
|
|
|
TCOM/SPP - LIMITED 1-2 LEVELS
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
8013708
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$266.00 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna of IA Commercial |
$342.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.00
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.00
|
| Rate for Payer: Medical Associates Commercial |
$285.00
|
| Rate for Payer: Midlands Choice Commercial |
$266.00
|
| Rate for Payer: United Healthcare Commercial |
$342.00
|
|
|
TCOM/SPP - LIMITED 1-2 LEVELS
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
8013708
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$189.92 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna of IA Commercial |
$342.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.00
|
| Rate for Payer: Aetna of IA Medicare |
$216.60
|
| Rate for Payer: Amerigroup Medicaid |
$191.79
|
| Rate for Payer: Amerigroup Medicare |
$191.90
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$190.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$189.92
|
| Rate for Payer: Medical Associates Commercial |
$285.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$190.00
|
| Rate for Payer: Midlands Choice Commercial |
$266.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$192.85
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$192.74
|
| Rate for Payer: Oscar Health of IA Commercial |
$285.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$285.00
|
| Rate for Payer: United Healthcare Commercial |
$342.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$224.20
|
| Rate for Payer: Wellmark IA HMO |
$281.48
|
| Rate for Payer: Wellmark IA PPO |
$309.63
|
|
|
TELEHEALTH FACILITY FEE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
CPT Q3014
|
| Hospital Charge Code |
7855053
|
|
Hospital Revenue Code
|
450
|
| 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
|
|
