|
terbinafine topical 1% Cre 15gm [VDMC]
|
Facility
|
IP
|
$33.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11337009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.18 |
| Max. Negotiated Rate |
$29.81 |
| Rate for Payer: Aetna of IA Commercial |
$29.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.81
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.84
|
| Rate for Payer: Medical Associates Commercial |
$24.84
|
| Rate for Payer: Midlands Choice Commercial |
$23.18
|
| Rate for Payer: United Healthcare Commercial |
$29.81
|
|
|
terbutaline 1 mg/mL 1 ml Inj SDV [VDMC]
|
Facility
|
OP
|
$25.41
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
10424044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$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: Molina Healthcare Managed Medicare |
$12.89
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.06
|
| 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
|
|
|
terbutaline 1 mg/mL 1 ml Inj SDV [VDMC]
|
Facility
|
IP
|
$25.41
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
10424044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.79 |
| Max. Negotiated Rate |
$22.87 |
| Rate for Payer: Aetna of IA Commercial |
$22.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.87
|
| Rate for Payer: Cash Price |
$20.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.06
|
| Rate for Payer: Medical Associates Commercial |
$19.06
|
| Rate for Payer: Midlands Choice Commercial |
$17.79
|
| Rate for Payer: United Healthcare Commercial |
$22.87
|
|
|
Testes Procedures With CC/MCC
|
Facility
|
IP
|
$20,972.22
|
|
|
Service Code
|
MS-DRG 711
|
| Hospital Charge Code |
478
|
| Min. Negotiated Rate |
$20,668.27 |
| Max. Negotiated Rate |
$20,972.22 |
| Rate for Payer: Amerigroup Medicaid |
$20,870.90
|
| 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 |
$8,462.08 |
| Max. Negotiated Rate |
$8,586.53 |
| Rate for Payer: Amerigroup Medicaid |
$8,545.04
|
| 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 Commercial |
$900.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$900.00
|
| Rate for Payer: Aetna of IA Medicare |
$570.00
|
| Rate for Payer: Amerigroup Medicaid |
$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: Molina Healthcare Managed Medicare |
$507.20
|
| Rate for Payer: Oscar Health of IA Commercial |
$750.00
|
| 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[VDMC]
|
Facility
|
OP
|
$351.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
12491246
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$178.17
|
| Rate for Payer: Oscar Health of IA Commercial |
$263.46
|
| 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[VDMC]
|
Facility
|
IP
|
$351.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
12491246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$245.90 |
| Max. Negotiated Rate |
$316.15 |
| 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 [VDMC]
|
Facility
|
IP
|
$77.60
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
10424113
|
|
Hospital Revenue Code
|
259
|
| 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 cypionate 200 mg/mL 1 ml IM SDV [VDMC]
|
Facility
|
OP
|
$77.60
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
10424113
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$39.36
|
| Rate for Payer: Oscar Health of IA Commercial |
$58.20
|
| 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 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: Molina Healthcare Managed Medicare |
$72.53
|
| Rate for Payer: Oscar Health of IA Commercial |
$107.25
|
| 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
|
IP
|
$143.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
8094267
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
|
|
TESTOSTERONE FREE
|
Facility
|
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: Molina Healthcare Managed Medicare |
$72.53
|
| Rate for Payer: Oscar Health of IA Commercial |
$107.25
|
| 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 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: Molina Healthcare Managed Medicare |
$72.02
|
| Rate for Payer: Oscar Health of IA Commercial |
$106.50
|
| 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: Molina Healthcare Managed Medicare |
$79.63
|
| Rate for Payer: Oscar Health of IA Commercial |
$117.75
|
| 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: Molina Healthcare Managed Medicare |
$107.02
|
| Rate for Payer: Oscar Health of IA Commercial |
$158.25
|
| 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/pertuss (Tdap) adult/adol 5 units-2.5 units-18.5 mcg/0.5 mL Sus [VDMC]
|
Facility
|
OP
|
$91.02
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
21188189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.49 |
| Max. Negotiated Rate |
$81.92 |
| Rate for Payer: Aetna of IA Commercial |
$81.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$81.92
|
| Rate for Payer: Aetna of IA Medicare |
$51.88
|
| Rate for Payer: Amerigroup Medicaid |
$45.94
|
| Rate for Payer: Amerigroup Medicare |
$45.97
|
| Rate for Payer: Cash Price |
$72.82
|
| Rate for Payer: Cash Price |
$72.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$68.26
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$45.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$45.49
|
| Rate for Payer: Medical Associates Commercial |
$68.26
|
| Rate for Payer: Medical Associates Managed Medicare |
$45.51
|
| Rate for Payer: Midlands Choice Commercial |
$63.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$46.19
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$46.17
|
| Rate for Payer: Oscar Health of IA Commercial |
$68.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$68.26
|
| Rate for Payer: United Healthcare Commercial |
$81.92
|
| Rate for Payer: United Healthcare Managed Medicare |
$53.70
|
| Rate for Payer: Wellmark IA HMO |
$62.00
|
| Rate for Payer: Wellmark IA PPO |
$68.20
|
|
|
tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2.5 units-18.5 mcg/0.5 mL Sus [VDMC]
|
Facility
|
IP
|
$91.02
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
21188189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.71 |
| Max. Negotiated Rate |
$81.92 |
| Rate for Payer: Aetna of IA Commercial |
$81.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$81.92
|
| Rate for Payer: Cash Price |
$72.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$68.26
|
| Rate for Payer: Medical Associates Commercial |
$68.26
|
| Rate for Payer: Midlands Choice Commercial |
$63.71
|
| Rate for Payer: United Healthcare Commercial |
$81.92
|
|
|
tetanus-diphth toxoids (Td) adult/adol 2 units-2 units/0.5 mL Sus[VDMC]
|
Facility
|
OP
|
$64.91
|
|
|
Service Code
|
HCPCS 90414
|
| Hospital Charge Code |
12698337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.44 |
| Max. Negotiated Rate |
$58.42 |
| Rate for Payer: Medical Associates Commercial |
$48.68
|
| 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 Managed Medicare |
$32.46
|
| Rate for Payer: Midlands Choice Commercial |
$45.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.94
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$32.92
|
| Rate for Payer: Oscar Health of IA Commercial |
$48.68
|
| 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[VDMC]
|
Facility
|
IP
|
$64.91
|
|
|
Service Code
|
HCPCS 90414
|
| Hospital Charge Code |
12698337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.44 |
| Max. Negotiated Rate |
$58.42 |
| Rate for Payer: Aetna of IA Commercial |
$58.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.42
|
| Rate for Payer: Cash Price |
$51.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.68
|
| Rate for Payer: Medical Associates Commercial |
$48.68
|
| Rate for Payer: Midlands Choice Commercial |
$45.44
|
| Rate for Payer: United Healthcare Commercial |
$58.42
|
|
