|
Vancomycin HCL 1gm/200ml IV [VDMC]
|
Facility
|
OP
|
$98.75
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23192247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.44 |
| Max. Negotiated Rate |
$88.88 |
| Rate for Payer: Aetna of IA Commercial |
$88.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.88
|
| Rate for Payer: Aetna of IA Medicare |
$56.29
|
| Rate for Payer: Amerigroup Medicaid |
$56.96
|
| Rate for Payer: Amerigroup Medicare |
$44.88
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$44.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.41
|
| Rate for Payer: Medical Associates Commercial |
$74.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$44.44
|
| Rate for Payer: Midlands Choice Commercial |
$69.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$51.10
|
| Rate for Payer: United Healthcare Commercial |
$88.88
|
| Rate for Payer: United Healthcare Managed Medicare |
$58.26
|
|
|
Vancomycin HCL 750mg/150ml IV [VDMC]
|
Facility
|
OP
|
$86.56
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23609821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.95 |
| Max. Negotiated Rate |
$77.91 |
| Rate for Payer: Aetna of IA Commercial |
$77.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$77.91
|
| Rate for Payer: Aetna of IA Medicare |
$49.34
|
| Rate for Payer: Amerigroup Medicaid |
$49.93
|
| Rate for Payer: Amerigroup Medicare |
$39.34
|
| Rate for Payer: Cash Price |
$69.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$64.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$38.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$49.45
|
| Rate for Payer: Medical Associates Commercial |
$64.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$38.95
|
| Rate for Payer: Midlands Choice Commercial |
$60.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$50.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$44.80
|
| Rate for Payer: United Healthcare Commercial |
$77.91
|
| Rate for Payer: United Healthcare Managed Medicare |
$51.07
|
|
|
Vancomycin HCL 750mg/150ml IV [VDMC]
|
Facility
|
IP
|
$86.56
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23609821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.59 |
| Max. Negotiated Rate |
$77.91 |
| Rate for Payer: Aetna of IA Commercial |
$77.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$77.91
|
| Rate for Payer: Cash Price |
$69.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$64.92
|
| Rate for Payer: Medical Associates Commercial |
$64.92
|
| Rate for Payer: Midlands Choice Commercial |
$60.59
|
| Rate for Payer: United Healthcare Commercial |
$77.91
|
|
|
VANCOMYCIN LEVEL
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
1634896
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
|
|
VANCOMYCIN LEVEL
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
1634896
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Aetna of IA Medicare |
$73.53
|
| Rate for Payer: Amerigroup Medicaid |
$74.41
|
| Rate for Payer: Amerigroup Medicare |
$58.63
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.68
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.05
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$66.76
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
|
|
VANCOMYCIN LEVEL
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
1634897
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Aetna of IA Medicare |
$73.53
|
| Rate for Payer: Amerigroup Medicaid |
$74.41
|
| Rate for Payer: Amerigroup Medicare |
$58.63
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.68
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.05
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$66.76
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
|
|
VANCOMYCIN LEVEL
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
1634897
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
|
|
varicella virus vaccine - Pow[VDMC]
|
Facility
|
IP
|
$324.06
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
12455194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$226.84 |
| Max. Negotiated Rate |
$291.65 |
| Rate for Payer: Aetna of IA Commercial |
$291.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$291.65
|
| Rate for Payer: Cash Price |
$259.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$243.04
|
| Rate for Payer: Medical Associates Commercial |
$243.04
|
| Rate for Payer: Midlands Choice Commercial |
$226.84
|
| Rate for Payer: United Healthcare Commercial |
$291.65
|
|
|
varicella virus vaccine - Pow[VDMC]
|
Facility
|
OP
|
$324.06
|
|
|
Service Code
|
HCPCS 90716
|
| Hospital Charge Code |
12455194
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$145.83 |
| Max. Negotiated Rate |
$291.65 |
| Rate for Payer: Aetna of IA Commercial |
$291.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$291.65
|
| Rate for Payer: Aetna of IA Medicare |
$184.71
|
| Rate for Payer: Amerigroup Medicaid |
$186.92
|
| Rate for Payer: Amerigroup Medicare |
$147.28
|
| Rate for Payer: Cash Price |
$259.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$243.04
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$145.83
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$185.10
|
| Rate for Payer: Medical Associates Commercial |
$243.04
|
| Rate for Payer: Medical Associates Managed Medicare |
$145.83
|
| Rate for Payer: Midlands Choice Commercial |
$226.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$187.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$167.70
|
| Rate for Payer: United Healthcare Commercial |
$291.65
|
| Rate for Payer: United Healthcare Managed Medicare |
$191.19
|
|
|
Varicella Zoster Virus IgG Antibody DMCL
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
CPT 86787
|
| Hospital Charge Code |
8037822
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of IA Commercial |
$94.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.50
|
| Rate for Payer: Aetna of IA Medicare |
$59.85
|
| Rate for Payer: Amerigroup Medicaid |
$60.56
|
| Rate for Payer: Amerigroup Medicare |
$47.72
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$47.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.98
|
| Rate for Payer: Medical Associates Commercial |
$78.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$47.25
|
| Rate for Payer: Midlands Choice Commercial |
$73.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$54.34
|
| Rate for Payer: United Healthcare Commercial |
$94.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.95
|
|
|
Varicella Zoster Virus IgG Antibody DMCL
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
CPT 86787
|
| Hospital Charge Code |
8037822
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of IA Commercial |
$94.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.50
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.75
|
| Rate for Payer: Medical Associates Commercial |
$78.75
|
| Rate for Payer: Midlands Choice Commercial |
$73.50
|
| Rate for Payer: United Healthcare Commercial |
$94.50
|
|
|
Varicella Zoster Virus IgM Antibody DMCL
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
CPT 86787
|
| Hospital Charge Code |
8037823
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of IA Commercial |
$94.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.50
|
| Rate for Payer: Aetna of IA Medicare |
$59.85
|
| Rate for Payer: Amerigroup Medicaid |
$60.56
|
| Rate for Payer: Amerigroup Medicare |
$47.72
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$47.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.98
|
| Rate for Payer: Medical Associates Commercial |
$78.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$47.25
|
| Rate for Payer: Midlands Choice Commercial |
$73.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$54.34
|
| Rate for Payer: United Healthcare Commercial |
$94.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.95
|
|
|
Varicella Zoster Virus IgM Antibody DMCL
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
CPT 86787
|
| Hospital Charge Code |
8037823
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of IA Commercial |
$94.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.50
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.75
|
| Rate for Payer: Medical Associates Commercial |
$78.75
|
| Rate for Payer: Midlands Choice Commercial |
$73.50
|
| Rate for Payer: United Healthcare Commercial |
$94.50
|
|
|
VASECTOMY UNIL OR BILAT
|
Professional
|
Both
|
$1,285.00
|
|
|
Service Code
|
CPT 55250
|
| Hospital Charge Code |
8068962
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$547.71 |
| Max. Negotiated Rate |
$963.75 |
| Rate for Payer: Cash Price |
$1,028.00
|
| Rate for Payer: Cash Price |
$1,028.00
|
| Rate for Payer: Medical Associates Commercial |
$963.75
|
| Rate for Payer: Midlands Choice Commercial |
$899.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$963.75
|
| Rate for Payer: United Healthcare Commercial |
$547.71
|
|
|
vasopressin 20 units/mL Inj Sol [VDMC]
|
Facility
|
OP
|
$204.26
|
|
|
Service Code
|
HCPCS J2598
|
| Hospital Charge Code |
10427728
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$91.92 |
| Max. Negotiated Rate |
$183.83 |
| Rate for Payer: Aetna of IA Commercial |
$183.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$183.83
|
| Rate for Payer: Aetna of IA Medicare |
$116.43
|
| Rate for Payer: Amerigroup Medicaid |
$117.82
|
| Rate for Payer: Amerigroup Medicare |
$92.84
|
| Rate for Payer: Cash Price |
$163.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$153.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$91.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$116.67
|
| Rate for Payer: Medical Associates Commercial |
$153.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$91.92
|
| Rate for Payer: Midlands Choice Commercial |
$142.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$118.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$183.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$120.51
|
|
|
vasopressin 20 units/mL Inj Sol [VDMC]
|
Facility
|
IP
|
$204.26
|
|
|
Service Code
|
HCPCS J2598
|
| Hospital Charge Code |
10427728
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$142.98 |
| Max. Negotiated Rate |
$183.83 |
| Rate for Payer: Aetna of IA Commercial |
$183.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$183.83
|
| Rate for Payer: Cash Price |
$163.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$153.19
|
| Rate for Payer: Medical Associates Commercial |
$153.19
|
| Rate for Payer: Midlands Choice Commercial |
$142.98
|
| Rate for Payer: United Healthcare Commercial |
$183.83
|
|
|
VDMC Cardiolite- Sestimibi
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
7922811
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna of IA Commercial |
$270.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$270.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$225.00
|
| Rate for Payer: Medical Associates Commercial |
$225.00
|
| Rate for Payer: Midlands Choice Commercial |
$210.00
|
| Rate for Payer: United Healthcare Commercial |
$270.00
|
|
|
VDMC Cardiolite- Sestimibi
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
7922811
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna of IA Commercial |
$270.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$270.00
|
| Rate for Payer: Aetna of IA Medicare |
$171.00
|
| Rate for Payer: Amerigroup Medicaid |
$173.04
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$225.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$171.36
|
| Rate for Payer: Medical Associates Commercial |
$225.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$210.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$173.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$155.25
|
| Rate for Payer: United Healthcare Commercial |
$270.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$177.00
|
|
|
VDMC Chest-Cad
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 0174T
|
| Hospital Charge Code |
7922825
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna of IA Commercial |
$27.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.00
|
| Rate for Payer: Aetna of IA Medicare |
$17.10
|
| Rate for Payer: Amerigroup Medicaid |
$17.30
|
| Rate for Payer: Amerigroup Medicare |
$13.63
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.14
|
| Rate for Payer: Medical Associates Commercial |
$22.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.50
|
| Rate for Payer: Midlands Choice Commercial |
$21.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.53
|
| Rate for Payer: United Healthcare Commercial |
$27.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.70
|
|
|
VDMC Chest-Cad
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 0174T
|
| Hospital Charge Code |
7922825
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna of IA Commercial |
$27.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.50
|
| Rate for Payer: Medical Associates Commercial |
$22.50
|
| Rate for Payer: Midlands Choice Commercial |
$21.00
|
| Rate for Payer: United Healthcare Commercial |
$27.00
|
|
|
VDMC CT Abdomen + Pelvis w/ Contrast
|
Facility
|
OP
|
$2,420.00
|
|
|
Service Code
|
CPT 74177
|
| Hospital Charge Code |
8027196
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,089.00 |
| Max. Negotiated Rate |
$2,178.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,178.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,178.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,379.40
|
| Rate for Payer: Amerigroup Medicaid |
$1,395.86
|
| Rate for Payer: Amerigroup Medicare |
$1,099.89
|
| Rate for Payer: Cash Price |
$1,936.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,815.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,089.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,382.30
|
| Rate for Payer: Medical Associates Commercial |
$1,815.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,089.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,694.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,402.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,252.35
|
| Rate for Payer: United Healthcare Commercial |
$2,178.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,427.80
|
|
|
VDMC CT Abdomen + Pelvis w/ Contrast
|
Facility
|
IP
|
$2,420.00
|
|
|
Service Code
|
CPT 74177
|
| Hospital Charge Code |
8027196
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,694.00 |
| Max. Negotiated Rate |
$2,178.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,178.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,178.00
|
| Rate for Payer: Cash Price |
$1,936.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,815.00
|
| Rate for Payer: Medical Associates Commercial |
$1,815.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,694.00
|
| Rate for Payer: United Healthcare Commercial |
$2,178.00
|
|
|
VDMC CT Abdomen + Pelvis w/o Contrast
|
Facility
|
OP
|
$1,860.00
|
|
|
Service Code
|
CPT 74176
|
| Hospital Charge Code |
8027197
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$837.00 |
| Max. Negotiated Rate |
$1,674.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,674.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,674.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,060.20
|
| Rate for Payer: Amerigroup Medicaid |
$1,072.85
|
| Rate for Payer: Amerigroup Medicare |
$845.37
|
| Rate for Payer: Cash Price |
$1,488.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,395.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$837.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,062.43
|
| Rate for Payer: Medical Associates Commercial |
$1,395.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$837.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,302.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,078.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$962.55
|
| Rate for Payer: United Healthcare Commercial |
$1,674.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,097.40
|
|
|
VDMC CT Abdomen + Pelvis w/o Contrast
|
Facility
|
IP
|
$1,860.00
|
|
|
Service Code
|
CPT 74176
|
| Hospital Charge Code |
8027197
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,302.00 |
| Max. Negotiated Rate |
$1,674.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,674.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,674.00
|
| Rate for Payer: Cash Price |
$1,488.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,395.00
|
| Rate for Payer: Medical Associates Commercial |
$1,395.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,302.00
|
| Rate for Payer: United Healthcare Commercial |
$1,674.00
|
|
|
VDMC CT Abdomen + Pelvis w/ + w/o Contrast
|
Facility
|
OP
|
$3,176.00
|
|
|
Service Code
|
CPT 74178
|
| Hospital Charge Code |
8027195
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,429.20 |
| Max. Negotiated Rate |
$2,858.40 |
| Rate for Payer: Aetna of IA Commercial |
$2,858.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,858.40
|
| Rate for Payer: Aetna of IA Medicare |
$1,810.32
|
| Rate for Payer: Amerigroup Medicaid |
$1,831.92
|
| Rate for Payer: Amerigroup Medicare |
$1,443.49
|
| Rate for Payer: Cash Price |
$2,540.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,382.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,429.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,814.13
|
| Rate for Payer: Medical Associates Commercial |
$2,382.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,429.20
|
| Rate for Payer: Midlands Choice Commercial |
$2,223.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,840.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,643.58
|
| Rate for Payer: United Healthcare Commercial |
$2,858.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,873.84
|
|
