|
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 Total and Free DMCL
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
8037809
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.63 |
| 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 |
$90.56
|
| Rate for Payer: Amerigroup Medicare |
$71.36
|
| 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 |
$70.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.68
|
| Rate for Payer: Medical Associates Commercial |
$117.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$70.65
|
| Rate for Payer: Midlands Choice Commercial |
$109.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.25
|
| Rate for Payer: United Healthcare Commercial |
$141.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$92.63
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
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 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 |
$49.63 |
| 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 |
$121.70
|
| Rate for Payer: Amerigroup Medicare |
$95.90
|
| 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 |
$94.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$120.52
|
| Rate for Payer: Medical Associates Commercial |
$158.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$94.95
|
| Rate for Payer: Midlands Choice Commercial |
$147.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$122.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.19
|
| Rate for Payer: United Healthcare Commercial |
$189.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$124.49
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
tetanus-diphtheria toxoids adult IM Susp 0.5 mL [VDMC]
|
Facility
|
OP
|
$88.34
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
10424318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.75 |
| Max. Negotiated Rate |
$88.25 |
| Rate for Payer: Aetna of IA Commercial |
$79.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$79.51
|
| Rate for Payer: Aetna of IA Medicare |
$50.35
|
| Rate for Payer: Amerigroup Medicaid |
$50.95
|
| Rate for Payer: Amerigroup Medicare |
$40.15
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$66.26
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$39.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$50.46
|
| Rate for Payer: Medical Associates Commercial |
$66.26
|
| Rate for Payer: Medical Associates Managed Medicare |
$39.75
|
| Rate for Payer: Midlands Choice Commercial |
$61.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$51.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.72
|
| Rate for Payer: United Healthcare Commercial |
$79.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$52.12
|
| Rate for Payer: Wellmark IA HMO WHPI |
$80.12
|
| Rate for Payer: Wellmark IA PPO |
$88.25
|
|
|
tetanus-diphtheria toxoids adult IM Susp 0.5 mL [VDMC]
|
Facility
|
IP
|
$88.34
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
10424318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$61.84 |
| Max. Negotiated Rate |
$79.51 |
| Rate for Payer: Aetna of IA Commercial |
$79.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$79.51
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$66.26
|
| Rate for Payer: Medical Associates Commercial |
$66.26
|
| Rate for Payer: Midlands Choice Commercial |
$61.84
|
| Rate for Payer: United Healthcare Commercial |
$79.51
|
|
|
tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2.5 units-18.5 mcg/0.5 mL Sus [VDMC]
|
Facility
|
IP
|
$90.45
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
21188189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.31 |
| Max. Negotiated Rate |
$81.40 |
| Rate for Payer: Aetna of IA Commercial |
$81.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$81.40
|
| Rate for Payer: Cash Price |
$72.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$67.83
|
| Rate for Payer: Medical Associates Commercial |
$67.83
|
| Rate for Payer: Midlands Choice Commercial |
$63.31
|
| Rate for Payer: United Healthcare Commercial |
$81.40
|
|
|
tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2.5 units-18.5 mcg/0.5 mL Sus [VDMC]
|
Facility
|
OP
|
$90.45
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
21188189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.70 |
| Max. Negotiated Rate |
$88.25 |
| Rate for Payer: Aetna of IA Commercial |
$81.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$81.40
|
| Rate for Payer: Aetna of IA Medicare |
$51.55
|
| Rate for Payer: Amerigroup Medicaid |
$52.17
|
| Rate for Payer: Amerigroup Medicare |
$41.11
|
| Rate for Payer: Cash Price |
$72.36
|
| Rate for Payer: Cash Price |
$72.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$67.83
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$40.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$51.66
|
| Rate for Payer: Medical Associates Commercial |
$67.83
|
| Rate for Payer: Medical Associates Managed Medicare |
$40.70
|
| Rate for Payer: Midlands Choice Commercial |
$63.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$52.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$46.81
|
| Rate for Payer: United Healthcare Commercial |
$81.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$53.36
|
| Rate for Payer: Wellmark IA HMO WHPI |
$80.12
|
| Rate for Payer: Wellmark IA PPO |
$88.25
|
|
|
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
|
|
|
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 |
$29.21 |
| 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: Aetna of IA Medicare |
$37.00
|
| Rate for Payer: Amerigroup Medicaid |
$37.44
|
| Rate for Payer: Amerigroup Medicare |
$29.50
|
| 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 |
$29.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.08
|
| Rate for Payer: Medical Associates Commercial |
$48.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.21
|
| Rate for Payer: Midlands Choice Commercial |
$45.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.59
|
| Rate for Payer: United Healthcare Commercial |
$58.42
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.30
|
|
|
tetanus immune globulin 250 units IM SD Sol 1 EA [VDMC]
|
Facility
|
OP
|
$942.00
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
10424180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$423.90 |
| Max. Negotiated Rate |
$847.80 |
| Rate for Payer: Aetna of IA Commercial |
$847.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$847.80
|
| Rate for Payer: Aetna of IA Medicare |
$536.94
|
| Rate for Payer: Amerigroup Medicaid |
$543.35
|
| Rate for Payer: Amerigroup Medicare |
$428.14
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$706.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$423.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$538.07
|
| Rate for Payer: Medical Associates Commercial |
$706.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$423.90
|
| Rate for Payer: Midlands Choice Commercial |
$659.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$545.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$487.48
|
| Rate for Payer: United Healthcare Commercial |
$847.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$555.78
|
|
|
tetanus immune globulin 250 units IM SD Sol 1 EA [VDMC]
|
Facility
|
IP
|
$942.00
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
10424180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$659.40 |
| Max. Negotiated Rate |
$847.80 |
| Rate for Payer: Aetna of IA Commercial |
$847.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$847.80
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$706.50
|
| Rate for Payer: Medical Associates Commercial |
$706.50
|
| Rate for Payer: Midlands Choice Commercial |
$659.40
|
| Rate for Payer: United Healthcare Commercial |
$847.80
|
|
|
tetracaine ophthalmic 0.5% 4 ml Sol [VDMC]
|
Facility
|
IP
|
$64.52
|
|
|
Service Code
|
NDC 00065-0741-12
|
| Hospital Charge Code |
12719136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.16 |
| Max. Negotiated Rate |
$58.06 |
| Rate for Payer: Aetna of IA Commercial |
$58.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.06
|
| Rate for Payer: Cash Price |
$51.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.39
|
| Rate for Payer: Medical Associates Commercial |
$48.39
|
| Rate for Payer: Midlands Choice Commercial |
$45.16
|
| Rate for Payer: United Healthcare Commercial |
$58.06
|
|
|
tetracaine ophthalmic 0.5% 4 ml Sol [VDMC]
|
Facility
|
OP
|
$64.52
|
|
|
Service Code
|
NDC 00065-0741-12
|
| Hospital Charge Code |
12719136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.03 |
| Max. Negotiated Rate |
$58.06 |
| Rate for Payer: Aetna of IA Commercial |
$58.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.06
|
| Rate for Payer: Aetna of IA Medicare |
$36.77
|
| Rate for Payer: Amerigroup Medicaid |
$37.21
|
| Rate for Payer: Amerigroup Medicare |
$29.32
|
| Rate for Payer: Cash Price |
$51.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.03
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$36.85
|
| Rate for Payer: Medical Associates Commercial |
$48.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.03
|
| Rate for Payer: Midlands Choice Commercial |
$45.16
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.39
|
| Rate for Payer: United Healthcare Commercial |
$58.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.06
|
|
|
Thawing Fee
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
8018868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$215.56 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Aetna of IA Medicare |
$29.64
|
| Rate for Payer: Amerigroup Medicaid |
$29.99
|
| Rate for Payer: Amerigroup Medicare |
$23.63
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$29.70
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.40
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.91
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.68
|
| Rate for Payer: Wellmark IA HMO WHPI |
$195.68
|
| Rate for Payer: Wellmark IA PPO |
$215.56
|
|
|
Thawing Fee
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
8018868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
|
|
theophylline 100 mg/24 hours ER Cap [VDMC]
|
Facility
|
OP
|
$12.79
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10610890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna of IA Commercial |
$11.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.51
|
| Rate for Payer: Aetna of IA Medicare |
$7.29
|
| Rate for Payer: Amerigroup Medicaid |
$7.38
|
| Rate for Payer: Amerigroup Medicare |
$5.81
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.59
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.30
|
| Rate for Payer: Medical Associates Commercial |
$9.59
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.75
|
| Rate for Payer: Midlands Choice Commercial |
$8.95
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.41
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.62
|
| Rate for Payer: United Healthcare Commercial |
$11.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.55
|
|
|
theophylline 100 mg/24 hours ER Cap [VDMC]
|
Facility
|
IP
|
$12.79
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10610890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna of IA Commercial |
$11.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.51
|
| Rate for Payer: Cash Price |
$10.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.59
|
| Rate for Payer: Medical Associates Commercial |
$9.59
|
| Rate for Payer: Midlands Choice Commercial |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$11.51
|
|
|
Theophylline DMCL
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
8037811
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$43.20 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of IA Commercial |
$86.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.40
|
| Rate for Payer: Aetna of IA Medicare |
$54.72
|
| Rate for Payer: Amerigroup Medicaid |
$55.37
|
| Rate for Payer: Amerigroup Medicare |
$43.63
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$43.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$54.84
|
| Rate for Payer: Medical Associates Commercial |
$72.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$43.20
|
| Rate for Payer: Midlands Choice Commercial |
$67.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$55.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$49.68
|
| Rate for Payer: United Healthcare Commercial |
$86.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$56.64
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
Theophylline DMCL
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
8037811
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of IA Commercial |
$86.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.40
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.00
|
| Rate for Payer: Medical Associates Commercial |
$72.00
|
| Rate for Payer: Midlands Choice Commercial |
$67.20
|
| Rate for Payer: United Healthcare Commercial |
$86.40
|
|
|
THERA ACTIVITIES 15 MIN, DIRECT
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 97530 GP
|
| Hospital Charge Code |
1374031
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
|
|
THERA ACTIVITIES 15 MIN, DIRECT
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 97530 GP
|
| Hospital Charge Code |
1374031
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$49.05 |
| Max. Negotiated Rate |
$165.57 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Aetna of IA Medicare |
$62.13
|
| Rate for Payer: Amerigroup Medicaid |
$62.87
|
| Rate for Payer: Amerigroup Medicare |
$49.54
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.26
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.05
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.41
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.31
|
| Rate for Payer: Wellmark IA HMO WHPI |
$150.31
|
| Rate for Payer: Wellmark IA PPO |
$165.57
|
|
|
THER ACTIVITIES DIRECT PER 15 MIN
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
1373450
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$49.05 |
| Max. Negotiated Rate |
$165.57 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Aetna of IA Medicare |
$62.13
|
| Rate for Payer: Amerigroup Medicaid |
$62.87
|
| Rate for Payer: Amerigroup Medicare |
$49.54
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.26
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.05
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.41
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.31
|
| Rate for Payer: Wellmark IA HMO WHPI |
$150.31
|
| Rate for Payer: Wellmark IA PPO |
$165.57
|
|
|
THER ACTIVITIES DIRECT PER 15 MIN
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
1373450
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of IA Commercial |
$98.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.10
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.75
|
| Rate for Payer: Medical Associates Commercial |
$81.75
|
| Rate for Payer: Midlands Choice Commercial |
$76.30
|
| Rate for Payer: United Healthcare Commercial |
$98.10
|
|
