|
diltiazem 30 mg Tab [VDMC]
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of IA Commercial |
$1.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.95
|
| Rate for Payer: Aetna of IA Medicare |
$1.23
|
| Rate for Payer: Amerigroup Medicaid |
$1.25
|
| Rate for Payer: Amerigroup Medicare |
$0.98
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.23
|
| Rate for Payer: Medical Associates Commercial |
$1.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.97
|
| Rate for Payer: Midlands Choice Commercial |
$1.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.28
|
|
|
diltiazem 30 mg Tab [VDMC]
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of IA Commercial |
$1.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.95
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.62
|
| Rate for Payer: Medical Associates Commercial |
$1.62
|
| Rate for Payer: Midlands Choice Commercial |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
|
|
dilTIAZem 5 mg/mL 5ml vial SOL SDV [VDMC]
|
Facility
|
OP
|
$31.96
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15382673
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$28.76 |
| Rate for Payer: Aetna of IA Commercial |
$28.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.76
|
| Rate for Payer: Aetna of IA Medicare |
$18.22
|
| Rate for Payer: Amerigroup Medicaid |
$18.43
|
| Rate for Payer: Amerigroup Medicare |
$14.53
|
| Rate for Payer: Cash Price |
$25.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.26
|
| Rate for Payer: Medical Associates Commercial |
$23.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.38
|
| Rate for Payer: Midlands Choice Commercial |
$22.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.54
|
| Rate for Payer: United Healthcare Commercial |
$28.76
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.86
|
|
|
dilTIAZem 5 mg/mL 5ml vial SOL SDV [VDMC]
|
Facility
|
IP
|
$31.96
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15382673
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$28.76 |
| Rate for Payer: Aetna of IA Commercial |
$28.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.76
|
| Rate for Payer: Cash Price |
$25.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.97
|
| Rate for Payer: Medical Associates Commercial |
$23.97
|
| Rate for Payer: Midlands Choice Commercial |
$22.37
|
| Rate for Payer: United Healthcare Commercial |
$28.76
|
|
|
diphenhydrAMINE 12.5 mg/5 mL 10 ml Oral Liq [VDMC]
|
Facility
|
IP
|
$7.59
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Aetna of IA Commercial |
$6.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.83
|
| Rate for Payer: Cash Price |
$6.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.69
|
| Rate for Payer: Medical Associates Commercial |
$5.69
|
| Rate for Payer: Midlands Choice Commercial |
$5.31
|
| Rate for Payer: United Healthcare Commercial |
$6.83
|
|
|
diphenhydrAMINE 12.5 mg/5 mL 10 ml Oral Liq [VDMC]
|
Facility
|
OP
|
$7.59
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Aetna of IA Commercial |
$6.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.83
|
| Rate for Payer: Aetna of IA Medicare |
$4.33
|
| Rate for Payer: Amerigroup Medicaid |
$4.38
|
| Rate for Payer: Amerigroup Medicare |
$3.45
|
| Rate for Payer: Cash Price |
$6.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.34
|
| Rate for Payer: Medical Associates Commercial |
$5.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.42
|
| Rate for Payer: Midlands Choice Commercial |
$5.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.93
|
| Rate for Payer: United Healthcare Commercial |
$6.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.48
|
|
|
diphenhydrAMINE 25 mg Cap [VDMC]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383688
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Aetna of IA Medicare |
$0.65
|
| Rate for Payer: Amerigroup Medicaid |
$0.65
|
| Rate for Payer: Amerigroup Medicare |
$0.52
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.51
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.59
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.67
|
|
|
diphenhydrAMINE 25 mg Cap [VDMC]
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383688
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
|
|
diphenhydrAMINE 50 mg Cap [VDMC]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383757
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Aetna of IA Medicare |
$0.64
|
| Rate for Payer: Amerigroup Medicaid |
$0.65
|
| Rate for Payer: Amerigroup Medicare |
$0.51
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.51
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.58
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.67
|
|
|
diphenhydrAMINE 50 mg Cap [VDMC]
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383757
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
|
|
diphenhydrAMINE 50 mg/mL 1ml SDV Inj [VDMC]
|
Facility
|
IP
|
$24.10
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
10429301
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.87 |
| Max. Negotiated Rate |
$21.69 |
| Rate for Payer: Aetna of IA Commercial |
$21.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.69
|
| Rate for Payer: Cash Price |
$19.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.07
|
| Rate for Payer: Medical Associates Commercial |
$18.07
|
| Rate for Payer: Midlands Choice Commercial |
$16.87
|
| Rate for Payer: United Healthcare Commercial |
$21.69
|
|
|
diphenhydrAMINE 50 mg/mL 1ml SDV Inj [VDMC]
|
Facility
|
OP
|
$24.10
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
10429301
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$21.69 |
| Rate for Payer: Aetna of IA Commercial |
$21.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.69
|
| Rate for Payer: Aetna of IA Medicare |
$13.73
|
| Rate for Payer: Amerigroup Medicaid |
$13.90
|
| Rate for Payer: Amerigroup Medicare |
$10.95
|
| Rate for Payer: Cash Price |
$19.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.76
|
| Rate for Payer: Medical Associates Commercial |
$18.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.84
|
| Rate for Payer: Midlands Choice Commercial |
$16.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.47
|
| Rate for Payer: United Healthcare Commercial |
$21.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.22
|
|
|
diphtheria/hepB/pertussis,acel/polio/tetanus - Sus SDV [VDMC]
|
Facility
|
OP
|
$145.58
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
12453437
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.51 |
| Max. Negotiated Rate |
$131.02 |
| Rate for Payer: Aetna of IA Commercial |
$131.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.02
|
| Rate for Payer: Aetna of IA Medicare |
$82.98
|
| Rate for Payer: Amerigroup Medicaid |
$83.97
|
| Rate for Payer: Amerigroup Medicare |
$66.17
|
| Rate for Payer: Cash Price |
$116.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$65.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$83.16
|
| Rate for Payer: Medical Associates Commercial |
$109.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.51
|
| Rate for Payer: Midlands Choice Commercial |
$101.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$84.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$75.34
|
| Rate for Payer: United Healthcare Commercial |
$131.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$85.89
|
|
|
diphtheria/hepB/pertussis,acel/polio/tetanus - Sus SDV [VDMC]
|
Facility
|
IP
|
$145.58
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
12453437
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$101.91 |
| Max. Negotiated Rate |
$131.02 |
| Rate for Payer: Aetna of IA Commercial |
$131.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.02
|
| Rate for Payer: Cash Price |
$116.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.19
|
| Rate for Payer: Medical Associates Commercial |
$109.19
|
| Rate for Payer: Midlands Choice Commercial |
$101.91
|
| Rate for Payer: United Healthcare Commercial |
$131.02
|
|
|
diphtheria/pertussis,acel/tetanus/polio - Sus SDV [VDMC]
|
Facility
|
IP
|
$109.58
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
12454583
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$76.71 |
| Max. Negotiated Rate |
$98.63 |
| Rate for Payer: Aetna of IA Commercial |
$98.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.63
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$82.19
|
| Rate for Payer: Medical Associates Commercial |
$82.19
|
| Rate for Payer: Midlands Choice Commercial |
$76.71
|
| Rate for Payer: United Healthcare Commercial |
$98.63
|
|
|
diphtheria/pertussis,acel/tetanus/polio - Sus SDV [VDMC]
|
Facility
|
OP
|
$109.58
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
12454583
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.31 |
| Max. Negotiated Rate |
$98.63 |
| Rate for Payer: Aetna of IA Commercial |
$98.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.63
|
| Rate for Payer: Aetna of IA Medicare |
$62.46
|
| Rate for Payer: Amerigroup Medicaid |
$63.21
|
| Rate for Payer: Amerigroup Medicare |
$49.81
|
| Rate for Payer: Cash Price |
$87.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$82.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.59
|
| Rate for Payer: Medical Associates Commercial |
$82.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.31
|
| Rate for Payer: Midlands Choice Commercial |
$76.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.71
|
| Rate for Payer: United Healthcare Commercial |
$98.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.65
|
|
|
diphtheria/tetanus/pertussis (DTaP) ped 25 units-10 units-58 mcg/0.5 mL Sus UD [VDMC]
|
Facility
|
OP
|
$61.30
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
24148567
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.59 |
| Max. Negotiated Rate |
$55.17 |
| Rate for Payer: Aetna of IA Commercial |
$55.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.17
|
| Rate for Payer: Aetna of IA Medicare |
$34.94
|
| Rate for Payer: Amerigroup Medicaid |
$35.36
|
| Rate for Payer: Amerigroup Medicare |
$27.86
|
| Rate for Payer: Cash Price |
$49.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.02
|
| Rate for Payer: Medical Associates Commercial |
$45.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.59
|
| Rate for Payer: Midlands Choice Commercial |
$42.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.72
|
| Rate for Payer: United Healthcare Commercial |
$55.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.17
|
|
|
diphtheria/tetanus/pertussis (DTaP) ped 25 units-10 units-58 mcg/0.5 mL Sus UD [VDMC]
|
Facility
|
IP
|
$61.30
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
24148567
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.91 |
| Max. Negotiated Rate |
$55.17 |
| Rate for Payer: Aetna of IA Commercial |
$55.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.17
|
| Rate for Payer: Cash Price |
$49.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.98
|
| Rate for Payer: Medical Associates Commercial |
$45.98
|
| Rate for Payer: Midlands Choice Commercial |
$42.91
|
| Rate for Payer: United Healthcare Commercial |
$55.17
|
|
|
diphth/haemophilus/pertussis/tetanus/polio SDV [VDMC]
|
Facility
|
IP
|
$128.26
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
12601246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$89.78 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Aetna of IA Commercial |
$115.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$115.43
|
| Rate for Payer: Cash Price |
$102.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.19
|
| Rate for Payer: Medical Associates Commercial |
$96.19
|
| Rate for Payer: Midlands Choice Commercial |
$89.78
|
| Rate for Payer: United Healthcare Commercial |
$115.43
|
|
|
diphth/haemophilus/pertussis/tetanus/polio SDV [VDMC]
|
Facility
|
OP
|
$128.26
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
12601246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$57.72 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Aetna of IA Commercial |
$115.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$115.43
|
| Rate for Payer: Aetna of IA Medicare |
$73.11
|
| Rate for Payer: Amerigroup Medicaid |
$73.98
|
| Rate for Payer: Amerigroup Medicare |
$58.29
|
| Rate for Payer: Cash Price |
$102.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.26
|
| Rate for Payer: Medical Associates Commercial |
$96.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.72
|
| Rate for Payer: Midlands Choice Commercial |
$89.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$66.37
|
| Rate for Payer: United Healthcare Commercial |
$115.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$75.67
|
|
|
dipyridamole 25 mg Tab [VDMC]
|
Facility
|
OP
|
$7.35
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383826
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna of IA Commercial |
$6.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.62
|
| Rate for Payer: Aetna of IA Medicare |
$4.19
|
| Rate for Payer: Amerigroup Medicaid |
$4.24
|
| Rate for Payer: Amerigroup Medicare |
$3.34
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.20
|
| Rate for Payer: Medical Associates Commercial |
$5.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.31
|
| Rate for Payer: Midlands Choice Commercial |
$5.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.80
|
| Rate for Payer: United Healthcare Commercial |
$6.62
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.34
|
|
|
dipyridamole 25 mg Tab [VDMC]
|
Facility
|
IP
|
$7.35
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383826
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna of IA Commercial |
$6.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.62
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.51
|
| Rate for Payer: Medical Associates Commercial |
$5.51
|
| Rate for Payer: Midlands Choice Commercial |
$5.15
|
| Rate for Payer: United Healthcare Commercial |
$6.62
|
|
|
dipyridamole 5 mg/mL 10 ml IV SDV [VDMC]
|
Facility
|
IP
|
$87.82
|
|
|
Service Code
|
HCPCS J1245
|
| Hospital Charge Code |
10383895
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$61.48 |
| Max. Negotiated Rate |
$79.04 |
| Rate for Payer: Aetna of IA Commercial |
$79.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$79.04
|
| Rate for Payer: Cash Price |
$70.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.87
|
| Rate for Payer: Medical Associates Commercial |
$65.87
|
| Rate for Payer: Midlands Choice Commercial |
$61.48
|
| Rate for Payer: United Healthcare Commercial |
$79.04
|
|
|
dipyridamole 5 mg/mL 10 ml IV SDV [VDMC]
|
Facility
|
OP
|
$87.82
|
|
|
Service Code
|
HCPCS J1245
|
| Hospital Charge Code |
10383895
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.52 |
| Max. Negotiated Rate |
$79.04 |
| Rate for Payer: Aetna of IA Commercial |
$79.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$79.04
|
| Rate for Payer: Aetna of IA Medicare |
$50.06
|
| Rate for Payer: Amerigroup Medicaid |
$50.66
|
| Rate for Payer: Amerigroup Medicare |
$39.92
|
| Rate for Payer: Cash Price |
$70.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.87
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$39.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$50.17
|
| Rate for Payer: Medical Associates Commercial |
$65.87
|
| Rate for Payer: Medical Associates Managed Medicare |
$39.52
|
| Rate for Payer: Midlands Choice Commercial |
$61.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$50.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.45
|
| Rate for Payer: United Healthcare Commercial |
$79.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$51.82
|
|
|
Direct Antiglobulin IgG DMCL
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
8037837
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Aetna of IA Medicare |
$33.06
|
| Rate for Payer: Amerigroup Medicaid |
$33.45
|
| Rate for Payer: Amerigroup Medicare |
$26.36
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.13
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.10
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.02
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.22
|
|
