|
bupivacaine 0.75% PF SDV Inj Sol 10 mL [VDMC]
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$22.41 |
| Rate for Payer: Aetna of IA Commercial |
$22.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.41
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.68
|
| Rate for Payer: Medical Associates Commercial |
$18.68
|
| Rate for Payer: Midlands Choice Commercial |
$17.43
|
| Rate for Payer: United Healthcare Commercial |
$22.41
|
|
|
bupivacaine 0.75% PF SDV Inj Sol 10 mL [VDMC]
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$22.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.41
|
| Rate for Payer: Aetna of IA Medicare |
$14.19
|
| Rate for Payer: Amerigroup Medicaid |
$14.36
|
| Rate for Payer: Amerigroup Medicare |
$11.32
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.22
|
| Rate for Payer: Medical Associates Commercial |
$18.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.21
|
| Rate for Payer: Midlands Choice Commercial |
$17.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.89
|
| Rate for Payer: United Healthcare Commercial |
$22.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.69
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
bupivacaine-epinephrine 0.5%-1:200,000- PF Inj 30 mL SDV [VDMC]
|
Facility
|
OP
|
$41.60
|
|
|
Service Code
|
HCPCS CN204
|
| Hospital Charge Code |
28796526
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$37.44 |
| Rate for Payer: Aetna of IA Commercial |
$37.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.44
|
| Rate for Payer: Aetna of IA Medicare |
$23.71
|
| Rate for Payer: Amerigroup Medicaid |
$23.99
|
| Rate for Payer: Amerigroup Medicare |
$18.91
|
| Rate for Payer: Cash Price |
$33.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.76
|
| Rate for Payer: Medical Associates Commercial |
$31.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.72
|
| Rate for Payer: Midlands Choice Commercial |
$29.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.53
|
| Rate for Payer: United Healthcare Commercial |
$37.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.54
|
|
|
bupivacaine-epinephrine 0.5%-1:200,000- PF Inj 30 mL SDV [VDMC]
|
Facility
|
IP
|
$41.60
|
|
|
Service Code
|
HCPCS CN204
|
| Hospital Charge Code |
28796526
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$37.44 |
| Rate for Payer: Aetna of IA Commercial |
$37.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.44
|
| Rate for Payer: Cash Price |
$33.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.20
|
| Rate for Payer: Medical Associates Commercial |
$31.20
|
| Rate for Payer: Midlands Choice Commercial |
$29.12
|
| Rate for Payer: United Healthcare Commercial |
$37.44
|
|
|
bupivacaine liposome 1.3% (13.3 mg/mL) Sus [VDMC]
|
Facility
|
OP
|
$1,524.47
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
10371742
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$686.01 |
| Max. Negotiated Rate |
$1,372.02 |
| Rate for Payer: Aetna of IA Commercial |
$1,372.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,372.02
|
| Rate for Payer: Aetna of IA Medicare |
$868.95
|
| Rate for Payer: Amerigroup Medicaid |
$879.31
|
| Rate for Payer: Amerigroup Medicare |
$692.87
|
| Rate for Payer: Cash Price |
$1,219.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,143.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$686.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$870.78
|
| Rate for Payer: Medical Associates Commercial |
$1,143.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$686.01
|
| Rate for Payer: Midlands Choice Commercial |
$1,067.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$883.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$788.91
|
| Rate for Payer: United Healthcare Commercial |
$1,372.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$899.44
|
|
|
bupivacaine liposome 1.3% (13.3 mg/mL) Sus [VDMC]
|
Facility
|
IP
|
$1,524.47
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
10371742
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,067.13 |
| Max. Negotiated Rate |
$1,372.02 |
| Rate for Payer: Aetna of IA Commercial |
$1,372.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,372.02
|
| Rate for Payer: Cash Price |
$1,219.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,143.35
|
| Rate for Payer: Medical Associates Commercial |
$1,143.35
|
| Rate for Payer: Midlands Choice Commercial |
$1,067.13
|
| Rate for Payer: United Healthcare Commercial |
$1,372.02
|
|
|
buprenorphine 10mcg/hr Transdermal [VDMC]
|
Facility
|
IP
|
$180.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372211
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$126.62 |
| Max. Negotiated Rate |
$162.79 |
| Rate for Payer: Aetna of IA Commercial |
$162.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.79
|
| Rate for Payer: Cash Price |
$144.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.66
|
| Rate for Payer: Medical Associates Commercial |
$135.66
|
| Rate for Payer: Midlands Choice Commercial |
$126.62
|
| Rate for Payer: United Healthcare Commercial |
$162.79
|
|
|
buprenorphine 10mcg/hr Transdermal [VDMC]
|
Facility
|
OP
|
$180.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372211
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$81.40 |
| Max. Negotiated Rate |
$162.79 |
| Rate for Payer: Aetna of IA Commercial |
$162.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.79
|
| Rate for Payer: Aetna of IA Medicare |
$103.10
|
| Rate for Payer: Amerigroup Medicaid |
$104.33
|
| Rate for Payer: Amerigroup Medicare |
$82.21
|
| Rate for Payer: Cash Price |
$144.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$103.32
|
| Rate for Payer: Medical Associates Commercial |
$135.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.40
|
| Rate for Payer: Midlands Choice Commercial |
$126.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.61
|
| Rate for Payer: United Healthcare Commercial |
$162.79
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.72
|
|
|
buprenorphine 5 mcg/hr Fil [VDMC]
|
Facility
|
OP
|
$131.24
|
|
|
Service Code
|
NDC 42858-0750-40
|
| Hospital Charge Code |
10372146
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$59.06 |
| Max. Negotiated Rate |
$118.12 |
| Rate for Payer: Aetna of IA Commercial |
$118.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$118.12
|
| Rate for Payer: Aetna of IA Medicare |
$74.81
|
| Rate for Payer: Amerigroup Medicaid |
$75.70
|
| Rate for Payer: Amerigroup Medicare |
$59.65
|
| Rate for Payer: Cash Price |
$104.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$98.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$59.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.96
|
| Rate for Payer: Medical Associates Commercial |
$98.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.06
|
| Rate for Payer: Midlands Choice Commercial |
$91.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$67.92
|
| Rate for Payer: United Healthcare Commercial |
$118.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$77.43
|
|
|
buprenorphine 5 mcg/hr Fil [VDMC]
|
Facility
|
IP
|
$131.24
|
|
|
Service Code
|
NDC 42858-0750-40
|
| Hospital Charge Code |
10372146
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$91.87 |
| Max. Negotiated Rate |
$118.12 |
| Rate for Payer: Aetna of IA Commercial |
$118.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$118.12
|
| Rate for Payer: Cash Price |
$104.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$98.43
|
| Rate for Payer: Medical Associates Commercial |
$98.43
|
| Rate for Payer: Midlands Choice Commercial |
$91.87
|
| Rate for Payer: United Healthcare Commercial |
$118.12
|
|
|
buPROPion 100 mg ER Tab/12 HR [VDMC]
|
Facility
|
IP
|
$3.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna of IA Commercial |
$2.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.80
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.33
|
| Rate for Payer: Medical Associates Commercial |
$2.33
|
| Rate for Payer: Midlands Choice Commercial |
$2.18
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
|
|
buPROPion 100 mg ER Tab/12 HR [VDMC]
|
Facility
|
OP
|
$3.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna of IA Commercial |
$2.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.80
|
| Rate for Payer: Aetna of IA Medicare |
$1.77
|
| Rate for Payer: Amerigroup Medicaid |
$1.80
|
| Rate for Payer: Amerigroup Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.78
|
| Rate for Payer: Medical Associates Commercial |
$2.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.40
|
| Rate for Payer: Midlands Choice Commercial |
$2.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.61
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.84
|
|
|
buPROPion 150 mg/24 hours ER Tab [VDMC]
|
Facility
|
OP
|
$4.43
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372414
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Aetna of IA Commercial |
$3.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.99
|
| Rate for Payer: Aetna of IA Medicare |
$2.53
|
| Rate for Payer: Amerigroup Medicaid |
$2.56
|
| Rate for Payer: Amerigroup Medicare |
$2.01
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.99
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.53
|
| Rate for Payer: Medical Associates Commercial |
$3.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.99
|
| Rate for Payer: Midlands Choice Commercial |
$3.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.29
|
| Rate for Payer: United Healthcare Commercial |
$3.99
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.62
|
|
|
buPROPion 150 mg/24 hours ER Tab [VDMC]
|
Facility
|
IP
|
$4.43
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372414
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Aetna of IA Commercial |
$3.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.99
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.32
|
| Rate for Payer: Medical Associates Commercial |
$3.32
|
| Rate for Payer: Midlands Choice Commercial |
$3.10
|
| Rate for Payer: United Healthcare Commercial |
$3.99
|
|
|
buPROPion 150 mg ER Tab/12 HR [VDMC]
|
Facility
|
OP
|
$2.26
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Aetna of IA Commercial |
$2.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.04
|
| Rate for Payer: Aetna of IA Medicare |
$1.29
|
| Rate for Payer: Amerigroup Medicaid |
$1.30
|
| Rate for Payer: Amerigroup Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.29
|
| Rate for Payer: Medical Associates Commercial |
$1.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.02
|
| Rate for Payer: Midlands Choice Commercial |
$1.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.17
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
|
buPROPion 150 mg ER Tab/12 HR [VDMC]
|
Facility
|
IP
|
$2.26
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Aetna of IA Commercial |
$2.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.04
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.70
|
| Rate for Payer: Medical Associates Commercial |
$1.70
|
| Rate for Payer: Midlands Choice Commercial |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
|
|
busPIRone 5 mg Tab [VDMC]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of IA Commercial |
$1.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.20
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Midlands Choice Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
busPIRone 5 mg Tab [VDMC]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372556
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of IA Commercial |
$1.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.20
|
| Rate for Payer: Aetna of IA Medicare |
$0.76
|
| Rate for Payer: Amerigroup Medicaid |
$0.77
|
| Rate for Payer: Amerigroup Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.76
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.60
|
| Rate for Payer: Midlands Choice Commercial |
$0.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.69
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.79
|
|
|
BX of cervix single/multiple w or w/o fulguration (removal cervical polyp)
|
Professional
|
Both
|
$422.00
|
|
|
Service Code
|
CPT 57500
|
| Hospital Charge Code |
8378890
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$68.41 |
| Max. Negotiated Rate |
$342.60 |
| Rate for Payer: Amerigroup Medicaid |
$69.08
|
| Rate for Payer: Cash Price |
$337.60
|
| Rate for Payer: Cash Price |
$337.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$68.41
|
| Rate for Payer: Medical Associates Commercial |
$316.50
|
| Rate for Payer: Midlands Choice Commercial |
$295.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$316.50
|
| Rate for Payer: United Healthcare Commercial |
$216.40
|
| Rate for Payer: Wellmark IA HMO WHPI |
$291.20
|
| Rate for Payer: Wellmark IA PPO |
$342.60
|
|
|
CA 125 DMCL
|
Facility
|
IP
|
$170.00
|
|
|
Service Code
|
CPT 86304
|
| Hospital Charge Code |
8037505
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
|
|
CA 125 DMCL
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
CPT 86304
|
| Hospital Charge Code |
8037505
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$41.83 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Aetna of IA Medicare |
$96.90
|
| Rate for Payer: Amerigroup Medicaid |
$98.06
|
| Rate for Payer: Amerigroup Medicare |
$77.26
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$76.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$97.10
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$76.50
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$98.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$87.98
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.30
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
CA 15 3 DMCL
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 86300
|
| Hospital Charge Code |
8519168
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
|
|
CA 15 3 DMCL
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 86300
|
| Hospital Charge Code |
8519168
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Aetna of IA Medicare |
$46.74
|
| Rate for Payer: Amerigroup Medicaid |
$47.30
|
| Rate for Payer: Amerigroup Medicare |
$37.27
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$36.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$46.84
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$36.90
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$47.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.44
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.38
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
CA 19 9 DMCL
|
Facility
|
IP
|
$170.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
8037506
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
|
|
CA 19 9 DMCL
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
8037506
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$41.83 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Aetna of IA Medicare |
$96.90
|
| Rate for Payer: Amerigroup Medicaid |
$98.06
|
| Rate for Payer: Amerigroup Medicare |
$77.26
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$76.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$97.10
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$76.50
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$98.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$87.98
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.30
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
