|
sodium thiosulfate 25% SDV Sol[VDMC]
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
HCPCS J0209
|
| Hospital Charge Code |
12817991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$365.40 |
| Rate for Payer: Aetna of IA Commercial |
$365.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$365.40
|
| Rate for Payer: Aetna of IA Medicare |
$231.42
|
| Rate for Payer: Amerigroup Medicaid |
$234.18
|
| Rate for Payer: Amerigroup Medicare |
$184.53
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$304.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$182.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$231.91
|
| Rate for Payer: Medical Associates Commercial |
$304.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$182.70
|
| Rate for Payer: Midlands Choice Commercial |
$284.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$235.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$210.10
|
| Rate for Payer: United Healthcare Commercial |
$365.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$239.54
|
|
|
Sodium, Urine
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
4021359
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
|
|
Sodium, Urine
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
4021359
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.45 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Aetna of IA Medicare |
$34.77
|
| Rate for Payer: Amerigroup Medicaid |
$35.18
|
| Rate for Payer: Amerigroup Medicare |
$27.72
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$34.84
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.45
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.57
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.99
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
SOFT TISSUE PROCEDURES WITH CC
|
Facility
|
IP
|
$14,547.62
|
|
|
Service Code
|
MSDRG 501
|
| Min. Negotiated Rate |
$14,336.78 |
| Max. Negotiated Rate |
$14,547.62 |
| Rate for Payer: Amerigroup Medicaid |
$14,477.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14,336.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14,547.62
|
|
|
SOFT TISSUE PROCEDURES WITH MCC
|
Facility
|
IP
|
$22,147.97
|
|
|
Service Code
|
MSDRG 500
|
| Min. Negotiated Rate |
$21,826.97 |
| Max. Negotiated Rate |
$22,147.97 |
| Rate for Payer: Amerigroup Medicaid |
$22,040.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21,826.97
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22,147.97
|
|
|
SOFT TISSUE PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$12,395.88
|
|
|
Service Code
|
MSDRG 502
|
| Min. Negotiated Rate |
$12,216.22 |
| Max. Negotiated Rate |
$12,395.88 |
| Rate for Payer: Amerigroup Medicaid |
$12,335.99
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12,216.22
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12,395.88
|
|
|
solifenacin 5 mg Tab [VDMC]
|
Facility
|
IP
|
$3.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421889
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of IA Commercial |
$3.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.20
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.67
|
| Rate for Payer: Medical Associates Commercial |
$2.67
|
| Rate for Payer: Midlands Choice Commercial |
$2.49
|
| Rate for Payer: United Healthcare Commercial |
$3.20
|
|
|
solifenacin 5 mg Tab [VDMC]
|
Facility
|
OP
|
$3.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421889
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of IA Commercial |
$3.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.20
|
| Rate for Payer: Aetna of IA Medicare |
$2.03
|
| Rate for Payer: Amerigroup Medicaid |
$2.05
|
| Rate for Payer: Amerigroup Medicare |
$1.62
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.67
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.03
|
| Rate for Payer: Medical Associates Commercial |
$2.67
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.60
|
| Rate for Payer: Midlands Choice Commercial |
$2.49
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$3.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.10
|
|
|
Soluble Transferrin Receptor DMCL
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT 84238
|
| Hospital Charge Code |
8820558
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.55 |
| Max. Negotiated Rate |
$134.33 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Aetna of IA Medicare |
$79.23
|
| Rate for Payer: Amerigroup Medicaid |
$80.18
|
| Rate for Payer: Amerigroup Medicare |
$63.18
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$62.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$79.40
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$62.55
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$80.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$71.93
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$121.95
|
| Rate for Payer: Wellmark IA PPO |
$134.33
|
|
|
Soluble Transferrin Receptor DMCL
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT 84238
|
| Hospital Charge Code |
8820558
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
|
|
SONICANCHOR KIT 2.5X10MM/ FOREC FIBRE #0
|
Facility
|
OP
|
$693.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8470642
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$311.85 |
| Max. Negotiated Rate |
$623.70 |
| Rate for Payer: Aetna of IA Commercial |
$623.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$623.70
|
| Rate for Payer: Aetna of IA Medicare |
$395.01
|
| Rate for Payer: Amerigroup Medicaid |
$399.72
|
| Rate for Payer: Amerigroup Medicare |
$314.97
|
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$519.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$311.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$395.84
|
| Rate for Payer: Medical Associates Commercial |
$519.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$311.85
|
| Rate for Payer: Midlands Choice Commercial |
$485.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$401.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$358.63
|
| Rate for Payer: United Healthcare Commercial |
$623.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$408.87
|
|
|
SONICANCHOR KIT 2.5X10MM/ FOREC FIBRE #0
|
Facility
|
IP
|
$693.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8470642
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$485.10 |
| Max. Negotiated Rate |
$623.70 |
| Rate for Payer: Aetna of IA Commercial |
$623.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$623.70
|
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$519.75
|
| Rate for Payer: Medical Associates Commercial |
$519.75
|
| Rate for Payer: Midlands Choice Commercial |
$485.10
|
| Rate for Payer: United Healthcare Commercial |
$623.70
|
|
|
SORBAFIX ABSORBABLE FIXATION SYSTEM
|
Facility
|
OP
|
$711.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8773701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$319.95 |
| Max. Negotiated Rate |
$639.90 |
| Rate for Payer: Aetna of IA Commercial |
$639.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$639.90
|
| Rate for Payer: Aetna of IA Medicare |
$405.27
|
| Rate for Payer: Amerigroup Medicaid |
$410.10
|
| Rate for Payer: Amerigroup Medicare |
$323.15
|
| Rate for Payer: Cash Price |
$568.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$533.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$319.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$406.12
|
| Rate for Payer: Medical Associates Commercial |
$533.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$319.95
|
| Rate for Payer: Midlands Choice Commercial |
$497.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$412.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$367.94
|
| Rate for Payer: United Healthcare Commercial |
$639.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$419.49
|
|
|
SORBAFIX ABSORBABLE FIXATION SYSTEM
|
Facility
|
IP
|
$711.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8773701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$497.70 |
| Max. Negotiated Rate |
$639.90 |
| Rate for Payer: Aetna of IA Commercial |
$639.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$639.90
|
| Rate for Payer: Cash Price |
$568.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$533.25
|
| Rate for Payer: Medical Associates Commercial |
$533.25
|
| Rate for Payer: Midlands Choice Commercial |
$497.70
|
| Rate for Payer: United Healthcare Commercial |
$639.90
|
|
|
sotalol 120 mg Tab [VDMC]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
17311425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of IA Commercial |
$1.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.16
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.74
|
| Rate for Payer: Medical Associates Commercial |
$0.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.67
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.76
|
|
|
sotalol 120 mg Tab [VDMC]
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
17311425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of IA Commercial |
$1.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.16
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.97
|
| Rate for Payer: Medical Associates Commercial |
$0.97
|
| Rate for Payer: Midlands Choice Commercial |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
|
|
sotalol 80 mg Tab [VDMC]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421958
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of IA Commercial |
$1.07
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.07
|
| Rate for Payer: Aetna of IA Medicare |
$0.68
|
| Rate for Payer: Amerigroup Medicaid |
$0.68
|
| Rate for Payer: Amerigroup Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.89
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.53
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.68
|
| Rate for Payer: Medical Associates Commercial |
$0.89
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.53
|
| Rate for Payer: Midlands Choice Commercial |
$0.83
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$1.07
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.70
|
|
|
sotalol 80 mg Tab [VDMC]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421958
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of IA Commercial |
$1.07
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.07
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$0.89
|
| Rate for Payer: Midlands Choice Commercial |
$0.83
|
| Rate for Payer: United Healthcare Commercial |
$1.07
|
|
|
SPADE TWO-STEP HAMMER TOE IMPLANT 34.5MMX3.0MMX14MM
|
Facility
|
IP
|
$2,223.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8868035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.10 |
| Max. Negotiated Rate |
$2,000.70 |
| Rate for Payer: Aetna of IA Commercial |
$2,000.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,000.70
|
| Rate for Payer: Cash Price |
$1,778.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,667.25
|
| Rate for Payer: Medical Associates Commercial |
$1,667.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,556.10
|
| Rate for Payer: United Healthcare Commercial |
$2,000.70
|
|
|
SPADE TWO-STEP HAMMER TOE IMPLANT 34.5MMX3.0MMX14MM
|
Facility
|
OP
|
$2,223.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8868035
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,000.35 |
| Max. Negotiated Rate |
$2,000.70 |
| Rate for Payer: Aetna of IA Commercial |
$2,000.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,000.70
|
| Rate for Payer: Aetna of IA Medicare |
$1,267.11
|
| Rate for Payer: Amerigroup Medicaid |
$1,282.23
|
| Rate for Payer: Amerigroup Medicare |
$1,010.35
|
| Rate for Payer: Cash Price |
$1,778.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,667.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,000.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,269.78
|
| Rate for Payer: Medical Associates Commercial |
$1,667.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,000.35
|
| Rate for Payer: Midlands Choice Commercial |
$1,556.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,288.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,150.40
|
| Rate for Payer: United Healthcare Commercial |
$2,000.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,311.57
|
|
|
SPADE TWO-STEP HAMMER TOE IMPLANT - 3.4MMX3.0MMX6MM
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8788811
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,260.00 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,620.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,620.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,350.00
|
| Rate for Payer: Medical Associates Commercial |
$1,350.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,260.00
|
| Rate for Payer: United Healthcare Commercial |
$1,620.00
|
|
|
SPADE TWO-STEP HAMMER TOE IMPLANT - 3.4MMX3.0MMX6MM
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8788811
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$810.00 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,620.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,620.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,026.00
|
| Rate for Payer: Amerigroup Medicaid |
$1,038.24
|
| Rate for Payer: Amerigroup Medicare |
$818.10
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,350.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$810.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,028.16
|
| Rate for Payer: Medical Associates Commercial |
$1,350.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$810.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,260.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,043.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$931.50
|
| Rate for Payer: United Healthcare Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,062.00
|
|
|
SPECIALTY CARE TRANSPORT
|
Facility
|
IP
|
$1,334.00
|
|
|
Service Code
|
HCPCS A0434 QN
|
| Hospital Charge Code |
7932763
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$933.80 |
| Max. Negotiated Rate |
$1,200.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,200.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,200.60
|
| Rate for Payer: Cash Price |
$1,067.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,000.50
|
| Rate for Payer: Medical Associates Commercial |
$1,000.50
|
| Rate for Payer: Midlands Choice Commercial |
$933.80
|
| Rate for Payer: United Healthcare Commercial |
$1,200.60
|
|
|
SPECIALTY CARE TRANSPORT
|
Facility
|
OP
|
$1,334.00
|
|
|
Service Code
|
HCPCS A0434 QN
|
| Hospital Charge Code |
7932763
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$600.30 |
| Max. Negotiated Rate |
$1,200.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,200.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,200.60
|
| Rate for Payer: Aetna of IA Medicare |
$760.38
|
| Rate for Payer: Amerigroup Medicaid |
$769.45
|
| Rate for Payer: Amerigroup Medicare |
$606.30
|
| Rate for Payer: Cash Price |
$1,067.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,000.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$600.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$761.98
|
| Rate for Payer: Medical Associates Commercial |
$1,000.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$600.30
|
| Rate for Payer: Midlands Choice Commercial |
$933.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$773.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$690.34
|
| Rate for Payer: United Healthcare Commercial |
$1,200.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,133.90
|
|
|
Speech Language Pathology Video Swallow
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
985772
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$272.30 |
| Max. Negotiated Rate |
$350.10 |
| Rate for Payer: Aetna of IA Commercial |
$350.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$350.10
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$291.75
|
| Rate for Payer: Medical Associates Commercial |
$291.75
|
| Rate for Payer: Midlands Choice Commercial |
$272.30
|
| Rate for Payer: United Healthcare Commercial |
$350.10
|
|
