|
TORIC LENS 17.0 SN6AT3+17.0D
|
Facility
OP
|
$891.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8934814
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$445.32 |
| Max. Negotiated Rate |
$801.90 |
| Rate for Payer: Aetna of IA Commercial |
$801.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$801.90
|
| Rate for Payer: Aetna of IA Medicare |
$507.87
|
| Rate for Payer: Amerigroup Medicaid |
$449.69
|
| Rate for Payer: Amerigroup Medicare |
$449.96
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$668.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$445.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$445.32
|
| Rate for Payer: Medical Associates Commercial |
$668.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$445.50
|
| Rate for Payer: Midlands Choice Commercial |
$623.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$452.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$668.25
|
| Rate for Payer: United Healthcare Commercial |
$801.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$525.69
|
|
|
TORIC LENS 17.0 SN6AT3+17.0D
|
Facility
IP
|
$891.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8934814
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$623.70 |
| Max. Negotiated Rate |
$801.90 |
| Rate for Payer: Aetna of IA Commercial |
$801.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$801.90
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$668.25
|
| Rate for Payer: Medical Associates Commercial |
$668.25
|
| Rate for Payer: Midlands Choice Commercial |
$623.70
|
| Rate for Payer: United Healthcare Commercial |
$801.90
|
|
|
TORPEDO, 4.00MM X 13CM
|
Facility
OP
|
$182.00
|
|
| Hospital Charge Code |
8047073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.96 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of IA Commercial |
$163.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$163.80
|
| Rate for Payer: Aetna of IA Medicare |
$103.74
|
| Rate for Payer: Amerigroup Medicaid |
$91.86
|
| Rate for Payer: Amerigroup Medicare |
$91.91
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$136.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$91.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$90.96
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$91.00
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$92.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$136.50
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$107.38
|
|
|
TORPEDO, 4.00MM X 13CM
|
Facility
IP
|
$182.00
|
|
| Hospital Charge Code |
8047073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of IA Commercial |
$163.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$163.80
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$136.50
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
|
|
TORPEDO, 4.00MMX7CM
|
Facility
OP
|
$182.00
|
|
| Hospital Charge Code |
8026442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.96 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of IA Commercial |
$163.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$163.80
|
| Rate for Payer: Aetna of IA Medicare |
$103.74
|
| Rate for Payer: Amerigroup Medicaid |
$91.86
|
| Rate for Payer: Amerigroup Medicare |
$91.91
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$136.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$91.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$90.96
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$91.00
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$92.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$136.50
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$107.38
|
|
|
TORPEDO, 4.00MMX7CM
|
Facility
IP
|
$182.00
|
|
| Hospital Charge Code |
8026442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of IA Commercial |
$163.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$163.80
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$136.50
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
|
|
torsemide 20 mg Tab
|
Facility
OP
|
$1.47
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700574
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna of IA Commercial |
$1.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.32
|
| Rate for Payer: Aetna of IA Medicare |
$0.84
|
| Rate for Payer: Amerigroup Medicaid |
$0.74
|
| Rate for Payer: Amerigroup Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$1.18
|
| 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 |
$0.74
|
| 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 |
$0.74
|
| Rate for Payer: Midlands Choice Commercial |
$1.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.87
|
|
|
torsemide 20 mg Tab
|
Facility
IP
|
$1.47
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700574
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna of IA Commercial |
$1.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.32
|
| Rate for Payer: Cash Price |
$1.18
|
| 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 |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$1.32
|
|
|
torsemide 5mg Tab
|
Facility
IP
|
$1.79
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of IA Commercial |
$1.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.61
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.34
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: United Healthcare Commercial |
$1.61
|
|
|
torsemide 5mg Tab
|
Facility
OP
|
$1.79
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of IA Commercial |
$1.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.61
|
| Rate for Payer: Aetna of IA Medicare |
$1.02
|
| Rate for Payer: Amerigroup Medicaid |
$0.90
|
| Rate for Payer: Amerigroup Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.90
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.61
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.06
|
|
|
TOTAL PROTEIN
|
Facility
OP
|
$40.00
|
|
|
Service Code
|
CPT 84155
|
| Hospital Charge Code |
8093946
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Aetna of IA Medicare |
$22.80
|
| Rate for Payer: Amerigroup Medicaid |
$20.19
|
| Rate for Payer: Amerigroup Medicare |
$20.20
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.99
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
TOTAL PROTEIN
|
Facility
OP
|
$40.00
|
|
|
Service Code
|
CPT 84155
|
| Hospital Charge Code |
633818
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Aetna of IA Medicare |
$22.80
|
| Rate for Payer: Amerigroup Medicaid |
$20.19
|
| Rate for Payer: Amerigroup Medicare |
$20.20
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.99
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
TOTAL PROTEIN
|
Facility
IP
|
$40.00
|
|
|
Service Code
|
CPT 84155
|
| Hospital Charge Code |
633818
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
|
|
TOTAL PROTEIN
|
Facility
IP
|
$40.00
|
|
|
Service Code
|
CPT 84155
|
| Hospital Charge Code |
8093946
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
|
|
T Pallidum Particle Agglutination DMCL
|
Facility
OP
|
$114.00
|
|
|
Service Code
|
CPT 86780
|
| Hospital Charge Code |
8037803
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$57.54
|
| Rate for Payer: Amerigroup Medicare |
$57.57
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.98
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.00
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
T Pallidum Particle Agglutination DMCL
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 86780
|
| Hospital Charge Code |
8037803
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
T-PLATE 3 HOLE 53MM OBLIQUE ANGLE
|
Facility
IP
|
$365.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$255.50 |
| Max. Negotiated Rate |
$328.50 |
| Rate for Payer: Aetna of IA Commercial |
$328.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$328.50
|
| Rate for Payer: Cash Price |
$292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$273.75
|
| Rate for Payer: Medical Associates Commercial |
$273.75
|
| Rate for Payer: Midlands Choice Commercial |
$255.50
|
| Rate for Payer: United Healthcare Commercial |
$328.50
|
|
|
T-PLATE 3 HOLE 53MM OBLIQUE ANGLE
|
Facility
OP
|
$365.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046785
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$182.43 |
| Max. Negotiated Rate |
$328.50 |
| Rate for Payer: Aetna of IA Commercial |
$328.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$328.50
|
| Rate for Payer: Aetna of IA Medicare |
$208.05
|
| Rate for Payer: Amerigroup Medicaid |
$184.22
|
| Rate for Payer: Amerigroup Medicare |
$184.32
|
| Rate for Payer: Cash Price |
$292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$273.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$182.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$182.43
|
| Rate for Payer: Medical Associates Commercial |
$273.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$182.50
|
| Rate for Payer: Midlands Choice Commercial |
$255.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$185.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$273.75
|
| Rate for Payer: United Healthcare Commercial |
$328.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$215.35
|
|
|
T-PLATE 3 HOLE 75MM SHAFT OBLIQUE ANGLE
|
Facility
IP
|
$400.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna of IA Commercial |
$360.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$360.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$300.00
|
| Rate for Payer: Medical Associates Commercial |
$300.00
|
| Rate for Payer: Midlands Choice Commercial |
$280.00
|
| Rate for Payer: United Healthcare Commercial |
$360.00
|
|
|
T-PLATE 3 HOLE 75MM SHAFT OBLIQUE ANGLE
|
Facility
OP
|
$400.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046784
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$199.92 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna of IA Commercial |
$360.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$360.00
|
| Rate for Payer: Aetna of IA Medicare |
$228.00
|
| Rate for Payer: Amerigroup Medicaid |
$201.88
|
| Rate for Payer: Amerigroup Medicare |
$202.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$300.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$200.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$199.92
|
| Rate for Payer: Medical Associates Commercial |
$300.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$200.00
|
| Rate for Payer: Midlands Choice Commercial |
$280.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$203.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$300.00
|
| Rate for Payer: United Healthcare Commercial |
$360.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$236.00
|
|
|
Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy With CC
|
Facility
IP
|
$25,682.80
|
|
|
Service Code
|
MS-DRG 012
|
| Hospital Charge Code |
702
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$25,682.80 |
| Rate for Payer: Amerigroup Medicaid |
$25,558.73
|
| 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 |
$25,310.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25,682.80
|
|
|
Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy With MCC
|
Facility
IP
|
$34,728.96
|
|
|
Service Code
|
MS-DRG 011
|
| Hospital Charge Code |
701
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$34,728.96 |
| Rate for Payer: Amerigroup Medicaid |
$34,561.19
|
| 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 |
$34,225.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$34,728.96
|
|
|
Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy Without CC/MCC
|
Facility
IP
|
$23,280.27
|
|
|
Service Code
|
MS-DRG 013
|
| Hospital Charge Code |
703
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$23,280.27 |
| Rate for Payer: Amerigroup Medicaid |
$23,167.80
|
| 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 |
$22,942.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23,280.27
|
|
|
Tracheostomy With MV >96 Hours or Principal Diagnosis Except Face, Mouth and Neck Without Major O.R. Procedures
|
Facility
IP
|
$99,873.94
|
|
|
Service Code
|
MS-DRG 004
|
| Hospital Charge Code |
695
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$99,873.94 |
| Rate for Payer: Amerigroup Medicaid |
$99,391.46
|
| 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 |
$98,426.49
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$99,873.94
|
|
|
traMADol 50 mg Tab
|
Facility
OP
|
$3.36
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700109
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Aetna of IA Commercial |
$3.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.02
|
| Rate for Payer: Aetna of IA Medicare |
$1.92
|
| Rate for Payer: Amerigroup Medicaid |
$1.70
|
| Rate for Payer: Amerigroup Medicare |
$1.70
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.52
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.68
|
| Rate for Payer: Medical Associates Commercial |
$2.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.68
|
| Rate for Payer: Midlands Choice Commercial |
$2.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.52
|
| Rate for Payer: United Healthcare Commercial |
$3.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.98
|
|
