|
BD Bone Density Axial + Vertebral Fx
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 77085
|
| Hospital Charge Code |
7820763
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$152.44 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of IA Commercial |
$274.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$274.50
|
| Rate for Payer: Aetna of IA Medicare |
$173.85
|
| Rate for Payer: Amerigroup Medicaid |
$153.93
|
| Rate for Payer: Amerigroup Medicare |
$154.02
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$152.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$152.44
|
| Rate for Payer: Medical Associates Commercial |
$228.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$152.50
|
| Rate for Payer: Midlands Choice Commercial |
$213.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$154.79
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$154.70
|
| Rate for Payer: Oscar Health of IA Commercial |
$228.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$228.75
|
| Rate for Payer: United Healthcare Commercial |
$274.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$179.95
|
| Rate for Payer: Wellmark IA HMO |
$245.52
|
| Rate for Payer: Wellmark IA PPO |
$270.07
|
|
|
BD Bone Density Axial + Vertebral Fx
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 77085
|
| Hospital Charge Code |
7820763
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of IA Commercial |
$274.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$274.50
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.75
|
| Rate for Payer: Medical Associates Commercial |
$228.75
|
| Rate for Payer: Midlands Choice Commercial |
$213.50
|
| Rate for Payer: United Healthcare Commercial |
$274.50
|
|
|
BD Bone Density DEXA App Skeleton
|
Facility
|
IP
|
$355.00
|
|
|
Service Code
|
CPT 77081
|
| Hospital Charge Code |
1167837
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna of IA Commercial |
$319.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$319.50
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$266.25
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
|
|
BD Bone Density DEXA App Skeleton
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
CPT 77081
|
| Hospital Charge Code |
1167837
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$177.43 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna of IA Commercial |
$319.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$319.50
|
| Rate for Payer: Aetna of IA Medicare |
$202.35
|
| Rate for Payer: Amerigroup Medicaid |
$179.17
|
| Rate for Payer: Amerigroup Medicare |
$179.28
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$266.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$177.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$177.43
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$177.50
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$180.16
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$180.06
|
| Rate for Payer: Oscar Health of IA Commercial |
$266.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$266.25
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$209.45
|
| Rate for Payer: Wellmark IA HMO |
$245.52
|
| Rate for Payer: Wellmark IA PPO |
$270.07
|
|
|
BD Bone Density DEXA App Skeleton Charge
|
Facility
|
IP
|
$355.00
|
|
|
Service Code
|
CPT 77081
|
| Hospital Charge Code |
8431525
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna of IA Commercial |
$319.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$319.50
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$266.25
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
|
|
BD Bone Density DEXA App Skeleton Charge
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
CPT 77081
|
| Hospital Charge Code |
8431525
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$177.43 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna of IA Commercial |
$319.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$319.50
|
| Rate for Payer: Aetna of IA Medicare |
$202.35
|
| Rate for Payer: Amerigroup Medicaid |
$179.17
|
| Rate for Payer: Amerigroup Medicare |
$179.28
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$266.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$177.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$177.43
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$177.50
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$180.16
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$180.06
|
| Rate for Payer: Oscar Health of IA Commercial |
$266.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$266.25
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$209.45
|
| Rate for Payer: Wellmark IA HMO |
$245.52
|
| Rate for Payer: Wellmark IA PPO |
$270.07
|
|
|
BD Bone Density DEXA Axial Skeleton
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
1167839
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$177.43 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna of IA Commercial |
$319.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$319.50
|
| Rate for Payer: Aetna of IA Medicare |
$202.35
|
| Rate for Payer: Amerigroup Medicaid |
$179.17
|
| Rate for Payer: Amerigroup Medicare |
$179.28
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$266.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$177.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$177.43
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$177.50
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$180.16
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$180.06
|
| Rate for Payer: Oscar Health of IA Commercial |
$266.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$266.25
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$209.45
|
| Rate for Payer: Wellmark IA HMO |
$245.52
|
| Rate for Payer: Wellmark IA PPO |
$270.07
|
|
|
BD Bone Density DEXA Axial Skeleton
|
Facility
|
IP
|
$355.00
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
1167839
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna of IA Commercial |
$319.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$319.50
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$266.25
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
|
|
BD Bone Density DEXA Axial Skeleton Charge
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
8431526
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$177.43 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna of IA Commercial |
$319.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$319.50
|
| Rate for Payer: Aetna of IA Medicare |
$202.35
|
| Rate for Payer: Amerigroup Medicaid |
$179.17
|
| Rate for Payer: Amerigroup Medicare |
$179.28
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$266.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$177.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$177.43
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$177.50
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$180.16
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$180.06
|
| Rate for Payer: Oscar Health of IA Commercial |
$266.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$266.25
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$209.45
|
| Rate for Payer: Wellmark IA HMO |
$245.52
|
| Rate for Payer: Wellmark IA PPO |
$270.07
|
|
|
BD Bone Density DEXA Axial Skeleton Charge
|
Facility
|
IP
|
$355.00
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
8431526
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$319.50 |
| Rate for Payer: Aetna of IA Commercial |
$319.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$319.50
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$266.25
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
|
|
BD Bone Density Vetebral Fracture
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
CPT 77086
|
| Hospital Charge Code |
1167841
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$85.40 |
| Max. Negotiated Rate |
$109.80 |
| Rate for Payer: Aetna of IA Commercial |
$109.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$109.80
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$91.50
|
| Rate for Payer: Medical Associates Commercial |
$91.50
|
| Rate for Payer: Midlands Choice Commercial |
$85.40
|
| Rate for Payer: United Healthcare Commercial |
$109.80
|
|
|
BD Bone Density Vetebral Fracture
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
CPT 77086
|
| Hospital Charge Code |
1167841
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$60.98 |
| Max. Negotiated Rate |
$270.07 |
| Rate for Payer: Aetna of IA Commercial |
$109.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$109.80
|
| Rate for Payer: Aetna of IA Medicare |
$69.54
|
| Rate for Payer: Amerigroup Medicaid |
$61.57
|
| Rate for Payer: Amerigroup Medicare |
$61.61
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$91.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$61.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$60.98
|
| Rate for Payer: Medical Associates Commercial |
$91.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$61.00
|
| Rate for Payer: Midlands Choice Commercial |
$85.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$61.92
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$61.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$91.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.50
|
| Rate for Payer: United Healthcare Commercial |
$109.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$71.98
|
| Rate for Payer: Wellmark IA HMO |
$245.52
|
| Rate for Payer: Wellmark IA PPO |
$270.07
|
|
|
BEHAV CHNG SMOKING >=11 MIN
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 99407
|
| Hospital Charge Code |
4770837
|
|
Hospital Revenue Code
|
942
|
| 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
|
|
|
BEHAV CHNG SMOKING >=11 MIN
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 99407
|
| Hospital Charge Code |
4770837
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$14.99 |
| 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 |
$15.14
|
| Rate for Payer: Amerigroup Medicare |
$15.15
|
| Rate for Payer: Cash Price |
$24.00
|
| 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 |
$15.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.99
|
| Rate for Payer: Medical Associates Commercial |
$22.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.00
|
| Rate for Payer: Midlands Choice Commercial |
$21.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.22
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$15.22
|
| Rate for Payer: Oscar Health of IA Commercial |
$22.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.50
|
| Rate for Payer: United Healthcare Commercial |
$27.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.70
|
| Rate for Payer: Wellmark IA HMO |
$17.98
|
| Rate for Payer: Wellmark IA PPO |
$19.78
|
|
|
BEHAV CHNG SMOKING 3-10 MIN
|
Facility
|
IP
|
$47.00
|
|
| Hospital Charge Code |
4770838
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$42.30 |
| Rate for Payer: Aetna of IA Commercial |
$42.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$42.30
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$35.25
|
| Rate for Payer: Medical Associates Commercial |
$35.25
|
| Rate for Payer: Midlands Choice Commercial |
$32.90
|
| Rate for Payer: United Healthcare Commercial |
$42.30
|
|
|
BEHAV CHNG SMOKING 3-10 MIN
|
Facility
|
OP
|
$47.00
|
|
| Hospital Charge Code |
4770838
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$23.49 |
| Max. Negotiated Rate |
$42.30 |
| Rate for Payer: Aetna of IA Commercial |
$42.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$42.30
|
| Rate for Payer: Aetna of IA Medicare |
$26.79
|
| Rate for Payer: Amerigroup Medicaid |
$23.72
|
| Rate for Payer: Amerigroup Medicare |
$23.74
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$35.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.49
|
| Rate for Payer: Medical Associates Commercial |
$35.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.50
|
| Rate for Payer: Midlands Choice Commercial |
$32.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.85
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$23.84
|
| Rate for Payer: Oscar Health of IA Commercial |
$35.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$35.25
|
| Rate for Payer: United Healthcare Commercial |
$42.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$27.73
|
|
|
Behavioral and Developmental Disorders
|
Facility
|
IP
|
$5,809.98
|
|
|
Service Code
|
MS-DRG 886
|
| Hospital Charge Code |
616
|
| Min. Negotiated Rate |
$5,725.78 |
| Max. Negotiated Rate |
$5,809.98 |
| Rate for Payer: Amerigroup Medicaid |
$5,781.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5,725.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,809.98
|
|
|
belatacept 250 mg Pow inj SDV [VDMC]
|
Facility
|
OP
|
$1,897.82
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
17804225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$948.53 |
| Max. Negotiated Rate |
$1,708.04 |
| Rate for Payer: Aetna of IA Commercial |
$1,708.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,708.04
|
| Rate for Payer: Aetna of IA Medicare |
$1,081.76
|
| Rate for Payer: Amerigroup Medicaid |
$957.83
|
| Rate for Payer: Amerigroup Medicare |
$958.40
|
| Rate for Payer: Cash Price |
$1,518.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,423.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$948.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$948.53
|
| Rate for Payer: Medical Associates Commercial |
$1,423.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$948.91
|
| Rate for Payer: Midlands Choice Commercial |
$1,328.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$963.14
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$962.57
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,423.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,423.36
|
| Rate for Payer: United Healthcare Commercial |
$1,708.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,119.71
|
|
|
belatacept 250 mg Pow inj SDV [VDMC]
|
Facility
|
IP
|
$1,897.82
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
17804225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,328.47 |
| Max. Negotiated Rate |
$1,708.04 |
| Rate for Payer: Aetna of IA Commercial |
$1,708.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,708.04
|
| Rate for Payer: Cash Price |
$1,518.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,423.36
|
| Rate for Payer: Medical Associates Commercial |
$1,423.36
|
| Rate for Payer: Midlands Choice Commercial |
$1,328.47
|
| Rate for Payer: United Healthcare Commercial |
$1,708.04
|
|
|
benazepril 10 mg Tab [VDMC]
|
Facility
|
OP
|
$2.51
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10369735
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna of IA Commercial |
$2.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.26
|
| Rate for Payer: Aetna of IA Medicare |
$1.43
|
| Rate for Payer: Amerigroup Medicaid |
$1.27
|
| Rate for Payer: Amerigroup Medicare |
$1.27
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.25
|
| Rate for Payer: Medical Associates Commercial |
$1.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.26
|
| Rate for Payer: Midlands Choice Commercial |
$1.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.27
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.27
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.88
|
| Rate for Payer: United Healthcare Commercial |
$2.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.48
|
|
|
benazepril 10 mg Tab [VDMC]
|
Facility
|
IP
|
$2.51
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10369735
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna of IA Commercial |
$2.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.26
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.88
|
| Rate for Payer: Medical Associates Commercial |
$1.88
|
| Rate for Payer: Midlands Choice Commercial |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$2.26
|
|
|
Benign Prostatic Hypertrophy With MCC
|
Facility
|
IP
|
$12,619.94
|
|
|
Service Code
|
MS-DRG 725
|
| Hospital Charge Code |
489
|
| Min. Negotiated Rate |
$12,437.04 |
| Max. Negotiated Rate |
$12,619.94 |
| Rate for Payer: Amerigroup Medicaid |
$12,558.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12,437.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12,619.94
|
|
|
Benign Prostatic Hypertrophy Without MCC
|
Facility
|
IP
|
$5,135.77
|
|
|
Service Code
|
MS-DRG 726
|
| Hospital Charge Code |
490
|
| Min. Negotiated Rate |
$5,061.34 |
| Max. Negotiated Rate |
$5,135.77 |
| Rate for Payer: Amerigroup Medicaid |
$5,110.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5,061.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,135.77
|
|
|
benzocaine-menthol topical 15 mg-3.6 mg Loz [VDMC]
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10369942
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of IA Commercial |
$1.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.38
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Midlands Choice Commercial |
$1.07
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
|
|
benzocaine-menthol topical 15 mg-3.6 mg Loz [VDMC]
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10369942
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of IA Commercial |
$1.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.38
|
| Rate for Payer: Aetna of IA Medicare |
$0.87
|
| Rate for Payer: Amerigroup Medicaid |
$0.77
|
| Rate for Payer: Amerigroup Medicare |
$0.77
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.76
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.77
|
| Rate for Payer: Midlands Choice Commercial |
$1.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.78
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.78
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.90
|
|
