|
bisacodyl 10 mg Supp [VDMC]
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 00574-7050-50
|
| Hospital Charge Code |
10370498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$3.95 |
| Rate for Payer: Aetna of IA Commercial |
$3.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.95
|
| Rate for Payer: Aetna of IA Medicare |
$2.50
|
| Rate for Payer: Amerigroup Medicaid |
$2.53
|
| Rate for Payer: Amerigroup Medicare |
$2.00
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.29
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.51
|
| Rate for Payer: Medical Associates Commercial |
$3.29
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.98
|
| Rate for Payer: Midlands Choice Commercial |
$3.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.27
|
| Rate for Payer: United Healthcare Commercial |
$3.95
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.59
|
|
|
bisacodyl 10 mg Supp [VDMC]
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 00574-7050-50
|
| Hospital Charge Code |
10370498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$3.95 |
| Rate for Payer: Aetna of IA Commercial |
$3.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.95
|
| Rate for Payer: Cash Price |
$3.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.29
|
| Rate for Payer: Medical Associates Commercial |
$3.29
|
| Rate for Payer: Midlands Choice Commercial |
$3.07
|
| Rate for Payer: United Healthcare Commercial |
$3.95
|
|
|
bisacodyl 5 mg Oral EC Tab [VDMC]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10370563
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of IA Commercial |
$0.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.97
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.81
|
| Rate for Payer: Medical Associates Commercial |
$0.81
|
| Rate for Payer: Midlands Choice Commercial |
$0.76
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
|
|
bisacodyl 5 mg Oral EC Tab [VDMC]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10370563
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of IA Commercial |
$0.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.97
|
| Rate for Payer: Aetna of IA Medicare |
$0.62
|
| Rate for Payer: Amerigroup Medicaid |
$0.62
|
| Rate for Payer: Amerigroup Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.81
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.62
|
| Rate for Payer: Medical Associates Commercial |
$0.81
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.49
|
| Rate for Payer: Midlands Choice Commercial |
$0.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.64
|
|
|
bismuth subsalicylate 262 mg Chew Tab [VDMC]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10370691
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of IA Commercial |
$1.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.08
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.90
|
| Rate for Payer: Medical Associates Commercial |
$0.90
|
| Rate for Payer: Midlands Choice Commercial |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.08
|
|
|
bismuth subsalicylate 262 mg Chew Tab [VDMC]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10370691
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of IA Commercial |
$1.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.08
|
| Rate for Payer: Aetna of IA Medicare |
$0.69
|
| Rate for Payer: Amerigroup Medicaid |
$0.69
|
| Rate for Payer: Amerigroup Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.69
|
| Rate for Payer: Medical Associates Commercial |
$0.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.54
|
| Rate for Payer: Midlands Choice Commercial |
$0.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.62
|
| Rate for Payer: United Healthcare Commercial |
$1.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.71
|
|
|
bisoprolol FUMARATE 5 mg Tab [VDMC]
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10370756
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Aetna of IA Commercial |
$3.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.86
|
| Rate for Payer: Aetna of IA Medicare |
$2.45
|
| Rate for Payer: Amerigroup Medicaid |
$2.47
|
| Rate for Payer: Amerigroup Medicare |
$1.95
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.45
|
| Rate for Payer: Medical Associates Commercial |
$3.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.93
|
| Rate for Payer: Midlands Choice Commercial |
$3.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.22
|
| Rate for Payer: United Healthcare Commercial |
$3.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.53
|
|
|
bisoprolol FUMARATE 5 mg Tab [VDMC]
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10370756
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Aetna of IA Commercial |
$3.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.86
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.22
|
| Rate for Payer: Medical Associates Commercial |
$3.22
|
| Rate for Payer: Midlands Choice Commercial |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$3.86
|
|
|
BK Virus DNA Quantitation DMCL
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
CPT 87799
|
| Hospital Charge Code |
8505605
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$86.50 |
| Max. Negotiated Rate |
$306.00 |
| Rate for Payer: Aetna of IA Commercial |
$306.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$306.00
|
| Rate for Payer: Aetna of IA Medicare |
$193.80
|
| Rate for Payer: Amerigroup Medicaid |
$196.11
|
| Rate for Payer: Amerigroup Medicare |
$154.53
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$255.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$153.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$194.21
|
| Rate for Payer: Medical Associates Commercial |
$255.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$153.00
|
| Rate for Payer: Midlands Choice Commercial |
$238.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$197.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$175.95
|
| Rate for Payer: United Healthcare Commercial |
$306.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$200.60
|
| Rate for Payer: Wellmark IA HMO WHPI |
$86.50
|
| Rate for Payer: Wellmark IA PPO |
$95.28
|
|
|
BK Virus DNA Quantitation DMCL
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
CPT 87799
|
| Hospital Charge Code |
8505605
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$238.00 |
| Max. Negotiated Rate |
$306.00 |
| Rate for Payer: Aetna of IA Commercial |
$306.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$306.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$255.00
|
| Rate for Payer: Medical Associates Commercial |
$255.00
|
| Rate for Payer: Midlands Choice Commercial |
$238.00
|
| Rate for Payer: United Healthcare Commercial |
$306.00
|
|
|
BLADDER CYSTO W/ CALIBRATION
|
Professional
|
Both
|
$907.00
|
|
|
Service Code
|
CPT 52281
|
| Hospital Charge Code |
8378864
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$248.30 |
| Max. Negotiated Rate |
$721.50 |
| Rate for Payer: Amerigroup Medicaid |
$250.73
|
| Rate for Payer: Cash Price |
$725.60
|
| Rate for Payer: Cash Price |
$725.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$248.30
|
| Rate for Payer: Medical Associates Commercial |
$680.25
|
| Rate for Payer: Midlands Choice Commercial |
$634.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$249.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$680.25
|
| Rate for Payer: United Healthcare Commercial |
$485.58
|
| Rate for Payer: Wellmark IA HMO WHPI |
$613.30
|
| Rate for Payer: Wellmark IA PPO |
$721.50
|
|
|
BLADDER SIMPLE CYSTOMETOGRAM (CMG)
|
Professional
|
Both
|
$621.00
|
|
|
Service Code
|
CPT 51725
|
| Hospital Charge Code |
8378863
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$89.94 |
| Max. Negotiated Rate |
$503.40 |
| Rate for Payer: Amerigroup Medicaid |
$90.83
|
| Rate for Payer: Cash Price |
$496.80
|
| Rate for Payer: Cash Price |
$496.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.94
|
| Rate for Payer: Medical Associates Commercial |
$465.75
|
| Rate for Payer: Midlands Choice Commercial |
$434.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$90.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$465.75
|
| Rate for Payer: United Healthcare Commercial |
$320.26
|
| Rate for Payer: Wellmark IA HMO WHPI |
$427.90
|
| Rate for Payer: Wellmark IA PPO |
$503.40
|
|
|
BLOOD GAS ARTERIAL, VENOUS, CORD
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 82803
|
| Hospital Charge Code |
633677
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of IA Commercial |
$157.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$157.50
|
| Rate for Payer: Aetna of IA Medicare |
$99.75
|
| Rate for Payer: Amerigroup Medicaid |
$100.94
|
| Rate for Payer: Amerigroup Medicare |
$79.54
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$131.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$78.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$99.96
|
| Rate for Payer: Medical Associates Commercial |
$131.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$78.75
|
| Rate for Payer: Midlands Choice Commercial |
$122.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$101.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$90.56
|
| Rate for Payer: United Healthcare Commercial |
$157.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.25
|
| Rate for Payer: Wellmark IA HMO WHPI |
$121.95
|
| Rate for Payer: Wellmark IA PPO |
$134.33
|
|
|
BLOOD GAS ARTERIAL, VENOUS, CORD
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 82803
|
| Hospital Charge Code |
633677
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of IA Commercial |
$157.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$157.50
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$131.25
|
| Rate for Payer: Medical Associates Commercial |
$131.25
|
| Rate for Payer: Midlands Choice Commercial |
$122.50
|
| Rate for Payer: United Healthcare Commercial |
$157.50
|
|
|
BLOOD GAS ARTERIAL, VENOUS, CORD
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 82803
|
| Hospital Charge Code |
633675
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of IA Commercial |
$157.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$157.50
|
| Rate for Payer: Aetna of IA Medicare |
$99.75
|
| Rate for Payer: Amerigroup Medicaid |
$100.94
|
| Rate for Payer: Amerigroup Medicare |
$79.54
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$131.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$78.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$99.96
|
| Rate for Payer: Medical Associates Commercial |
$131.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$78.75
|
| Rate for Payer: Midlands Choice Commercial |
$122.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$101.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$90.56
|
| Rate for Payer: United Healthcare Commercial |
$157.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.25
|
| Rate for Payer: Wellmark IA HMO WHPI |
$121.95
|
| Rate for Payer: Wellmark IA PPO |
$134.33
|
|
|
BLOOD GAS ARTERIAL, VENOUS, CORD
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 82803
|
| Hospital Charge Code |
633675
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of IA Commercial |
$157.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$157.50
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$131.25
|
| Rate for Payer: Medical Associates Commercial |
$131.25
|
| Rate for Payer: Midlands Choice Commercial |
$122.50
|
| Rate for Payer: United Healthcare Commercial |
$157.50
|
|
|
BLOOD PH
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
4106782
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
BLOOD PH
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
4106782
|
|
Hospital Revenue Code
|
301
|
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$61.68
|
| Rate for Payer: Wellmark IA PPO |
$67.95
|
|
|
BLOOD PH
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
4110801
|
|
Hospital Revenue Code
|
301
|
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$61.68
|
| Rate for Payer: Wellmark IA PPO |
$67.95
|
|
|
BLOOD PH
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
4110801
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
BLOOD TRANSFUSION-ED
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
4864934
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$553.70 |
| Max. Negotiated Rate |
$711.90 |
| Rate for Payer: Aetna of IA Commercial |
$711.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$711.90
|
| Rate for Payer: Cash Price |
$632.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$593.25
|
| Rate for Payer: Medical Associates Commercial |
$593.25
|
| Rate for Payer: Midlands Choice Commercial |
$553.70
|
| Rate for Payer: United Healthcare Commercial |
$711.90
|
|
|
BLOOD TRANSFUSION-ED
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
4864934
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$355.95 |
| Max. Negotiated Rate |
$711.90 |
| Rate for Payer: Aetna of IA Commercial |
$711.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$711.90
|
| Rate for Payer: Aetna of IA Medicare |
$450.87
|
| Rate for Payer: Amerigroup Medicaid |
$456.25
|
| Rate for Payer: Amerigroup Medicare |
$359.51
|
| Rate for Payer: Cash Price |
$632.80
|
| Rate for Payer: Cash Price |
$632.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$593.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$355.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$451.82
|
| Rate for Payer: Medical Associates Commercial |
$593.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$355.95
|
| Rate for Payer: Midlands Choice Commercial |
$553.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$458.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$409.34
|
| Rate for Payer: United Healthcare Commercial |
$711.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$466.69
|
| Rate for Payer: Wellmark IA HMO WHPI |
$431.78
|
| Rate for Payer: Wellmark IA PPO |
$475.63
|
|
|
BLOOD TRANSFUSION-OB
|
Facility
|
IP
|
$684.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
7763434
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$478.80 |
| Max. Negotiated Rate |
$615.60 |
| Rate for Payer: Aetna of IA Commercial |
$615.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$615.60
|
| Rate for Payer: Cash Price |
$547.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$513.00
|
| Rate for Payer: Medical Associates Commercial |
$513.00
|
| Rate for Payer: Midlands Choice Commercial |
$478.80
|
| Rate for Payer: United Healthcare Commercial |
$615.60
|
|
|
BLOOD TRANSFUSION-OB
|
Facility
|
OP
|
$684.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
7763434
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$307.80 |
| Max. Negotiated Rate |
$615.60 |
| Rate for Payer: Aetna of IA Commercial |
$615.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$615.60
|
| Rate for Payer: Aetna of IA Medicare |
$389.88
|
| Rate for Payer: Amerigroup Medicaid |
$394.53
|
| Rate for Payer: Amerigroup Medicare |
$310.88
|
| Rate for Payer: Cash Price |
$547.20
|
| Rate for Payer: Cash Price |
$547.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$513.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$307.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$390.70
|
| Rate for Payer: Medical Associates Commercial |
$513.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$307.80
|
| Rate for Payer: Midlands Choice Commercial |
$478.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$396.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$353.97
|
| Rate for Payer: United Healthcare Commercial |
$615.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$403.56
|
| Rate for Payer: Wellmark IA HMO WHPI |
$431.78
|
| Rate for Payer: Wellmark IA PPO |
$475.63
|
|
|
BLOOD TRANSFUSION, SCHEDULED
|
Facility
|
IP
|
$684.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
8012930
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$478.80 |
| Max. Negotiated Rate |
$615.60 |
| Rate for Payer: Aetna of IA Commercial |
$615.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$615.60
|
| Rate for Payer: Cash Price |
$547.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$513.00
|
| Rate for Payer: Medical Associates Commercial |
$513.00
|
| Rate for Payer: Midlands Choice Commercial |
$478.80
|
| Rate for Payer: United Healthcare Commercial |
$615.60
|
|
