|
BB TAK (OLIVE WIRE)
|
Facility
|
IP
|
$77.00
|
|
| Hospital Charge Code |
8047045
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$69.30 |
| Rate for Payer: Aetna of IA Commercial |
$69.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.30
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.75
|
| Rate for Payer: Medical Associates Commercial |
$57.75
|
| Rate for Payer: Midlands Choice Commercial |
$53.90
|
| Rate for Payer: United Healthcare Commercial |
$69.30
|
|
|
BB TAK (OLIVE WIRE)
|
Facility
|
OP
|
$77.00
|
|
| Hospital Charge Code |
8047045
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$69.30 |
| Rate for Payer: Aetna of IA Commercial |
$69.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.30
|
| Rate for Payer: Aetna of IA Medicare |
$43.89
|
| Rate for Payer: Amerigroup Medicaid |
$44.41
|
| Rate for Payer: Amerigroup Medicare |
$35.00
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$34.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$43.98
|
| Rate for Payer: Medical Associates Commercial |
$57.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$34.65
|
| Rate for Payer: Midlands Choice Commercial |
$53.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$44.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.85
|
| Rate for Payer: United Healthcare Commercial |
$69.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$45.43
|
|
|
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 Axial + Vertebral Fx
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 77085
|
| Hospital Charge Code |
7820763
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$137.25 |
| 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 |
$175.92
|
| Rate for Payer: Amerigroup Medicare |
$138.62
|
| 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 |
$137.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$174.22
|
| Rate for Payer: Medical Associates Commercial |
$228.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$137.25
|
| Rate for Payer: Midlands Choice Commercial |
$213.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$176.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$157.84
|
| Rate for Payer: United Healthcare Commercial |
$274.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$179.95
|
|
|
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 |
$159.75 |
| 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 |
$204.76
|
| Rate for Payer: Amerigroup Medicare |
$161.35
|
| 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 |
$159.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$202.78
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$159.75
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$205.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$183.71
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$209.45
|
|
|
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 |
$159.75 |
| 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 |
$204.76
|
| Rate for Payer: Amerigroup Medicare |
$161.35
|
| 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 |
$159.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$202.78
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$159.75
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$205.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$183.71
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$209.45
|
|
|
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 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
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
1167839
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$159.75 |
| 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 |
$204.76
|
| Rate for Payer: Amerigroup Medicare |
$161.35
|
| 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 |
$159.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$202.78
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$159.75
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$205.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$183.71
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$209.45
|
|
|
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 DEXA Axial Skeleton Charge
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
8431526
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$159.75 |
| 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 |
$204.76
|
| Rate for Payer: Amerigroup Medicare |
$161.35
|
| 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 |
$159.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$202.78
|
| Rate for Payer: Medical Associates Commercial |
$266.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$159.75
|
| Rate for Payer: Midlands Choice Commercial |
$248.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$205.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$183.71
|
| Rate for Payer: United Healthcare Commercial |
$319.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$209.45
|
|
|
BD Bone Density Vetebral Fracture
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
CPT 77086
|
| Hospital Charge Code |
1167841
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$54.90 |
| 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: Aetna of IA Medicare |
$69.54
|
| Rate for Payer: Amerigroup Medicaid |
$70.37
|
| Rate for Payer: Amerigroup Medicare |
$55.45
|
| 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 |
$54.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.69
|
| Rate for Payer: Medical Associates Commercial |
$91.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.90
|
| Rate for Payer: Midlands Choice Commercial |
$85.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.13
|
| Rate for Payer: United Healthcare Commercial |
$109.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$71.98
|
|
|
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
|
|
|
BEH AND QUAL ANALYSIS OF VOICE AND RESONANCE
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 92524 GN
|
| Hospital Charge Code |
8925758
|
|
Hospital Revenue Code
|
441
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
|
|
BEH AND QUAL ANALYSIS OF VOICE AND RESONANCE
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 92524 GN
|
| Hospital Charge Code |
8925758
|
|
Hospital Revenue Code
|
441
|
| Min. Negotiated Rate |
$103.50 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Aetna of IA Medicare |
$131.10
|
| Rate for Payer: Amerigroup Medicaid |
$132.66
|
| Rate for Payer: Amerigroup Medicare |
$104.53
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$103.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$131.38
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$103.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$133.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$119.03
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$135.70
|
|
|
BEHAV CHNG SMOKING >=11 MIN
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 99407
|
| Hospital Charge Code |
4770837
|
|
Hospital Revenue Code
|
942
|
| 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
|
|
|
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 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 |
$21.15 |
| 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 |
$27.11
|
| Rate for Payer: Amerigroup Medicare |
$21.36
|
| 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 |
$21.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.85
|
| Rate for Payer: Medical Associates Commercial |
$35.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.15
|
| Rate for Payer: Midlands Choice Commercial |
$32.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.32
|
| Rate for Payer: United Healthcare Commercial |
$42.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$27.73
|
|
|
belatacept 250 mg Pow inj SDV [VDMC]
|
Facility
|
OP
|
$2,039.76
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
17804225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$917.89 |
| Max. Negotiated Rate |
$1,835.78 |
| Rate for Payer: Aetna of IA Commercial |
$1,835.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,835.78
|
| Rate for Payer: Aetna of IA Medicare |
$1,162.66
|
| Rate for Payer: Amerigroup Medicaid |
$1,176.53
|
| Rate for Payer: Amerigroup Medicare |
$927.07
|
| Rate for Payer: Cash Price |
$1,631.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,529.82
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$917.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,165.11
|
| Rate for Payer: Medical Associates Commercial |
$1,529.82
|
| Rate for Payer: Medical Associates Managed Medicare |
$917.89
|
| Rate for Payer: Midlands Choice Commercial |
$1,427.83
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,182.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,055.58
|
| Rate for Payer: United Healthcare Commercial |
$1,835.78
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,203.46
|
|
|
belatacept 250 mg Pow inj SDV [VDMC]
|
Facility
|
IP
|
$2,039.76
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
17804225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,427.83 |
| Max. Negotiated Rate |
$1,835.78 |
| Rate for Payer: Aetna of IA Commercial |
$1,835.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,835.78
|
| Rate for Payer: Cash Price |
$1,631.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,529.82
|
| Rate for Payer: Medical Associates Commercial |
$1,529.82
|
| Rate for Payer: Midlands Choice Commercial |
$1,427.83
|
| Rate for Payer: United Healthcare Commercial |
$1,835.78
|
|
|
belimumab 120 mg Pow [VDMC]
|
Facility
|
IP
|
$1,326.20
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
27276766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$928.34 |
| Max. Negotiated Rate |
$1,193.58 |
| Rate for Payer: Aetna of IA Commercial |
$1,193.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,193.58
|
| Rate for Payer: Cash Price |
$1,060.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$994.65
|
| Rate for Payer: Medical Associates Commercial |
$994.65
|
| Rate for Payer: Midlands Choice Commercial |
$928.34
|
| Rate for Payer: United Healthcare Commercial |
$1,193.58
|
|
|
belimumab 120 mg Pow [VDMC]
|
Facility
|
OP
|
$1,326.20
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
27276766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$596.79 |
| Max. Negotiated Rate |
$1,193.58 |
| Rate for Payer: Aetna of IA Commercial |
$1,193.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,193.58
|
| Rate for Payer: Aetna of IA Medicare |
$755.93
|
| Rate for Payer: Amerigroup Medicaid |
$764.95
|
| Rate for Payer: Amerigroup Medicare |
$602.76
|
| Rate for Payer: Cash Price |
$1,060.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$994.65
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$596.79
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$757.53
|
| Rate for Payer: Medical Associates Commercial |
$994.65
|
| Rate for Payer: Medical Associates Managed Medicare |
$596.79
|
| Rate for Payer: Midlands Choice Commercial |
$928.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$768.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$686.31
|
| Rate for Payer: United Healthcare Commercial |
$1,193.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$782.46
|
|
|
belimumab 400 mg Pow [VDMC]
|
Facility
|
OP
|
$4,187.14
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
27276990
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,884.21 |
| Max. Negotiated Rate |
$3,768.43 |
| Rate for Payer: Aetna of IA Commercial |
$3,768.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,768.43
|
| Rate for Payer: Aetna of IA Medicare |
$2,386.67
|
| Rate for Payer: Amerigroup Medicaid |
$2,415.14
|
| Rate for Payer: Amerigroup Medicare |
$1,903.06
|
| Rate for Payer: Cash Price |
$3,349.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,140.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,884.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,391.69
|
| Rate for Payer: Medical Associates Commercial |
$3,140.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,884.21
|
| Rate for Payer: Midlands Choice Commercial |
$2,931.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,426.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,166.84
|
| Rate for Payer: United Healthcare Commercial |
$3,768.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,470.41
|
|
