|
T3 Reverse DMCL
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 84482
|
| Hospital Charge Code |
8037805
|
|
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
|
|
|
T3 Reverse DMCL
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 84482
|
| Hospital Charge Code |
8037805
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.63 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
T3 Total DMCL
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
8037806
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
|
|
T3 Total DMCL
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 84480
|
| Hospital Charge Code |
8037806
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Aetna of IA Medicare |
$59.28
|
| Rate for Payer: Amerigroup Medicaid |
$59.99
|
| Rate for Payer: Amerigroup Medicare |
$47.27
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$46.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.40
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$46.80
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$53.82
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.36
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
T4
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
CPT 84436
|
| Hospital Charge Code |
7928767
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Aetna of IA Medicare |
$37.05
|
| Rate for Payer: Amerigroup Medicaid |
$37.49
|
| Rate for Payer: Amerigroup Medicare |
$29.54
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.13
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.25
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.64
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.35
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
T4
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
CPT 84436
|
| Hospital Charge Code |
7928767
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
|
|
T4 FREE
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
4021360
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
|
|
T4 FREE
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
4021360
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Aetna of IA Medicare |
$46.74
|
| Rate for Payer: Amerigroup Medicaid |
$47.30
|
| Rate for Payer: Amerigroup Medicare |
$37.27
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$36.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$46.84
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$36.90
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$47.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.44
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.38
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
TA 45 3.5MM LOAD
|
Facility
|
IP
|
$119.00
|
|
| Hospital Charge Code |
8026284
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
TA 45 3.5MM LOAD
|
Facility
|
OP
|
$119.00
|
|
| Hospital Charge Code |
8026284
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
TA 45 3.5MM STAPLER
|
Facility
|
IP
|
$477.00
|
|
| Hospital Charge Code |
8026072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$333.90 |
| Max. Negotiated Rate |
$429.30 |
| Rate for Payer: Aetna of IA Commercial |
$429.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$429.30
|
| Rate for Payer: Cash Price |
$381.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$357.75
|
| Rate for Payer: Medical Associates Commercial |
$357.75
|
| Rate for Payer: Midlands Choice Commercial |
$333.90
|
| Rate for Payer: United Healthcare Commercial |
$429.30
|
|
|
TA 45 3.5MM STAPLER
|
Facility
|
OP
|
$477.00
|
|
| Hospital Charge Code |
8026072
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$214.65 |
| Max. Negotiated Rate |
$429.30 |
| Rate for Payer: Aetna of IA Commercial |
$429.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$429.30
|
| Rate for Payer: Aetna of IA Medicare |
$271.89
|
| Rate for Payer: Amerigroup Medicaid |
$275.13
|
| Rate for Payer: Amerigroup Medicare |
$216.80
|
| Rate for Payer: Cash Price |
$381.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$357.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$214.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$272.46
|
| Rate for Payer: Medical Associates Commercial |
$357.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$214.65
|
| Rate for Payer: Midlands Choice Commercial |
$333.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$276.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$246.85
|
| Rate for Payer: United Healthcare Commercial |
$429.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$281.43
|
|
|
tacrolimus 0.5 mg Oral Cap [VDMC]
|
Facility
|
IP
|
$3.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: Aetna of IA Commercial |
$2.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.95
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.46
|
| Rate for Payer: Medical Associates Commercial |
$2.46
|
| Rate for Payer: Midlands Choice Commercial |
$2.29
|
| Rate for Payer: United Healthcare Commercial |
$2.95
|
|
|
tacrolimus 0.5 mg Oral Cap [VDMC]
|
Facility
|
OP
|
$3.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: Aetna of IA Commercial |
$2.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.95
|
| Rate for Payer: Aetna of IA Medicare |
$1.87
|
| Rate for Payer: Amerigroup Medicaid |
$1.89
|
| Rate for Payer: Amerigroup Medicare |
$1.49
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.46
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.87
|
| Rate for Payer: Medical Associates Commercial |
$2.46
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.47
|
| Rate for Payer: Midlands Choice Commercial |
$2.29
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.69
|
| Rate for Payer: United Healthcare Commercial |
$2.95
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.93
|
|
|
Tacrolimus Level DMCL
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
8037807
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
|
|
Tacrolimus Level DMCL
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 80197
|
| Hospital Charge Code |
8037807
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Aetna of IA Medicare |
$85.50
|
| Rate for Payer: Amerigroup Medicaid |
$86.52
|
| Rate for Payer: Amerigroup Medicare |
$68.18
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$85.68
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$86.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$77.62
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$88.50
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
tadalafil 5 mg Tab [VDMC]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423354
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Aetna of IA Medicare |
$0.70
|
| Rate for Payer: Amerigroup Medicaid |
$0.71
|
| Rate for Payer: Amerigroup Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.70
|
| Rate for Payer: Medical Associates Commercial |
$0.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.55
|
| Rate for Payer: Midlands Choice Commercial |
$0.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.72
|
|
|
tadalafil 5 mg Tab [VDMC]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423354
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.92
|
| Rate for Payer: Medical Associates Commercial |
$0.92
|
| Rate for Payer: Midlands Choice Commercial |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
|
|
tafasitamab-CXIX 200 mg SDV [VDMC]
|
Facility
|
IP
|
$2,837.00
|
|
|
Service Code
|
HCPCS J9349
|
| Hospital Charge Code |
23872251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,985.90 |
| Max. Negotiated Rate |
$2,553.30 |
| Rate for Payer: Aetna of IA Commercial |
$2,553.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,553.30
|
| Rate for Payer: Cash Price |
$2,269.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,127.75
|
| Rate for Payer: Medical Associates Commercial |
$2,127.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,985.90
|
| Rate for Payer: United Healthcare Commercial |
$2,553.30
|
|
|
tafasitamab-CXIX 200 mg SDV [VDMC]
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
HCPCS J9349
|
| Hospital Charge Code |
23872251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,276.65 |
| Max. Negotiated Rate |
$2,553.30 |
| Rate for Payer: Aetna of IA Commercial |
$2,553.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,553.30
|
| Rate for Payer: Aetna of IA Medicare |
$1,617.09
|
| Rate for Payer: Amerigroup Medicaid |
$1,636.38
|
| Rate for Payer: Amerigroup Medicare |
$1,289.42
|
| Rate for Payer: Cash Price |
$2,269.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,127.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,276.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,620.49
|
| Rate for Payer: Medical Associates Commercial |
$2,127.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,276.65
|
| Rate for Payer: Midlands Choice Commercial |
$1,985.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,644.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,468.15
|
| Rate for Payer: United Healthcare Commercial |
$2,553.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,673.83
|
|
|
TALAR DOME LARGE
|
Facility
|
IP
|
$3,330.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8831373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,331.00 |
| Max. Negotiated Rate |
$2,997.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,997.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,997.00
|
| Rate for Payer: Cash Price |
$2,664.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,497.50
|
| Rate for Payer: Medical Associates Commercial |
$2,497.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,331.00
|
| Rate for Payer: United Healthcare Commercial |
$2,997.00
|
|
|
TALAR DOME LARGE
|
Facility
|
OP
|
$3,330.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8831373
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,498.50 |
| Max. Negotiated Rate |
$2,997.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,997.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,997.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,898.10
|
| Rate for Payer: Amerigroup Medicaid |
$1,920.74
|
| Rate for Payer: Amerigroup Medicare |
$1,513.48
|
| Rate for Payer: Cash Price |
$2,664.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,497.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,498.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,902.10
|
| Rate for Payer: Medical Associates Commercial |
$2,497.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,498.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,331.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,930.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,723.28
|
| Rate for Payer: United Healthcare Commercial |
$2,997.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,964.70
|
|
|
TALAR DOME MEDIUM
|
Facility
|
OP
|
$2,691.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8783238
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,210.95 |
| Max. Negotiated Rate |
$2,421.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,421.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,421.90
|
| Rate for Payer: Aetna of IA Medicare |
$1,533.87
|
| Rate for Payer: Amerigroup Medicaid |
$1,552.17
|
| Rate for Payer: Amerigroup Medicare |
$1,223.06
|
| Rate for Payer: Cash Price |
$2,152.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,018.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,210.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,537.10
|
| Rate for Payer: Medical Associates Commercial |
$2,018.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,210.95
|
| Rate for Payer: Midlands Choice Commercial |
$1,883.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,559.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,392.59
|
| Rate for Payer: United Healthcare Commercial |
$2,421.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,587.69
|
|
|
TALAR DOME MEDIUM
|
Facility
|
IP
|
$2,691.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8783238
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,883.70 |
| Max. Negotiated Rate |
$2,421.90 |
| Rate for Payer: Aetna of IA Commercial |
$2,421.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,421.90
|
| Rate for Payer: Cash Price |
$2,152.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,018.25
|
| Rate for Payer: Medical Associates Commercial |
$2,018.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,883.70
|
| Rate for Payer: United Healthcare Commercial |
$2,421.90
|
|
|
tamoxifen 10 mg Tab [VDMC]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423425
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of IA Commercial |
$1.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.28
|
| Rate for Payer: Aetna of IA Medicare |
$0.81
|
| Rate for Payer: Amerigroup Medicaid |
$0.82
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.81
|
| Rate for Payer: Medical Associates Commercial |
$1.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.64
|
| Rate for Payer: Midlands Choice Commercial |
$0.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.73
|
| Rate for Payer: United Healthcare Commercial |
$1.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.84
|
|
