|
docusate sodium 150 mg/15 mL Oral Liq [VDMC]
|
Facility
|
IP
|
$2.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384244
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Aetna of IA Commercial |
$2.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.16
|
| Rate for Payer: Medical Associates Commercial |
$2.16
|
| Rate for Payer: Midlands Choice Commercial |
$2.02
|
| Rate for Payer: United Healthcare Commercial |
$2.59
|
|
|
donepezil 10 mg Tab [VDMC]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384451
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.09
|
| Rate for Payer: Medical Associates Commercial |
$1.09
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
|
|
donepezil 10 mg Tab [VDMC]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384451
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Aetna of IA Medicare |
$0.83
|
| Rate for Payer: Amerigroup Medicaid |
$0.73
|
| Rate for Payer: Amerigroup Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.72
|
| Rate for Payer: Medical Associates Commercial |
$1.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.73
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.74
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.74
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.86
|
|
|
Do Not Use - Hetastarch Premix Additive [VDMC]
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11237097
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of IA Commercial |
$45.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.00
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.50
|
| Rate for Payer: Medical Associates Commercial |
$37.50
|
| Rate for Payer: Midlands Choice Commercial |
$35.00
|
| Rate for Payer: United Healthcare Commercial |
$45.00
|
|
|
Do Not Use - Hetastarch Premix Additive [VDMC]
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11237097
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of IA Commercial |
$45.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.00
|
| Rate for Payer: Aetna of IA Medicare |
$28.50
|
| Rate for Payer: Amerigroup Medicaid |
$25.24
|
| Rate for Payer: Amerigroup Medicare |
$25.25
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$25.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.99
|
| Rate for Payer: Medical Associates Commercial |
$37.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.00
|
| Rate for Payer: Midlands Choice Commercial |
$35.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.38
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$25.36
|
| Rate for Payer: Oscar Health of IA Commercial |
$37.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$37.50
|
| Rate for Payer: United Healthcare Commercial |
$45.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$29.50
|
|
|
dopamine/dextrose 5% 400MG/250ML [VDMC]
|
Facility
|
OP
|
$102.26
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
10430775
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$51.11 |
| Max. Negotiated Rate |
$92.03 |
| Rate for Payer: Aetna of IA Commercial |
$92.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$92.03
|
| Rate for Payer: Aetna of IA Medicare |
$58.29
|
| Rate for Payer: Amerigroup Medicaid |
$51.61
|
| Rate for Payer: Amerigroup Medicare |
$51.64
|
| Rate for Payer: Cash Price |
$81.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$76.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.13
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$51.11
|
| Rate for Payer: Medical Associates Commercial |
$76.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.13
|
| Rate for Payer: Midlands Choice Commercial |
$71.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$51.90
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$51.87
|
| Rate for Payer: Oscar Health of IA Commercial |
$76.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$76.70
|
| Rate for Payer: United Healthcare Commercial |
$92.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$60.33
|
|
|
dopamine/dextrose 5% 400MG/250ML [VDMC]
|
Facility
|
IP
|
$102.26
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
10430775
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$71.58 |
| Max. Negotiated Rate |
$92.03 |
| Rate for Payer: Aetna of IA Commercial |
$92.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$92.03
|
| Rate for Payer: Cash Price |
$81.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$76.70
|
| Rate for Payer: Medical Associates Commercial |
$76.70
|
| Rate for Payer: Midlands Choice Commercial |
$71.58
|
| Rate for Payer: United Healthcare Commercial |
$92.03
|
|
|
dorzolamide Ophth 2% Sol 10 ml [VDMC]
|
Facility
|
IP
|
$52.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.57 |
| Max. Negotiated Rate |
$47.02 |
| Rate for Payer: Aetna of IA Commercial |
$47.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.02
|
| Rate for Payer: Cash Price |
$41.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.18
|
| Rate for Payer: Medical Associates Commercial |
$39.18
|
| Rate for Payer: Midlands Choice Commercial |
$36.57
|
| Rate for Payer: United Healthcare Commercial |
$47.02
|
|
|
dorzolamide Ophth 2% Sol 10 ml [VDMC]
|
Facility
|
OP
|
$52.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.11 |
| Max. Negotiated Rate |
$47.02 |
| Rate for Payer: Aetna of IA Commercial |
$47.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.02
|
| Rate for Payer: Aetna of IA Medicare |
$29.78
|
| Rate for Payer: Amerigroup Medicaid |
$26.37
|
| Rate for Payer: Amerigroup Medicare |
$26.38
|
| Rate for Payer: Cash Price |
$41.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.11
|
| Rate for Payer: Medical Associates Commercial |
$39.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.12
|
| Rate for Payer: Midlands Choice Commercial |
$36.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.51
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$26.50
|
| Rate for Payer: Oscar Health of IA Commercial |
$39.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.18
|
| Rate for Payer: United Healthcare Commercial |
$47.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.82
|
|
|
dorzolamide-timolol Ophth 22.3mg-6.8mg Sol [VDMC]
|
Facility
|
OP
|
$55.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384593
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.55 |
| Max. Negotiated Rate |
$49.61 |
| Rate for Payer: Aetna of IA Commercial |
$49.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.61
|
| Rate for Payer: Aetna of IA Medicare |
$31.42
|
| Rate for Payer: Amerigroup Medicaid |
$27.82
|
| Rate for Payer: Amerigroup Medicare |
$27.84
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27.55
|
| Rate for Payer: Medical Associates Commercial |
$41.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.56
|
| Rate for Payer: Midlands Choice Commercial |
$38.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.97
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$27.96
|
| Rate for Payer: Oscar Health of IA Commercial |
$41.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$41.34
|
| Rate for Payer: United Healthcare Commercial |
$49.61
|
| Rate for Payer: United Healthcare Managed Medicare |
$32.52
|
|
|
dorzolamide-timolol Ophth 22.3mg-6.8mg Sol [VDMC]
|
Facility
|
IP
|
$55.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384593
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$49.61 |
| Rate for Payer: Aetna of IA Commercial |
$49.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.61
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.34
|
| Rate for Payer: Medical Associates Commercial |
$41.34
|
| Rate for Payer: Midlands Choice Commercial |
$38.58
|
| Rate for Payer: United Healthcare Commercial |
$49.61
|
|
|
DOT Urine Drug Collection
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
4022798
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
|
|
DOT Urine Drug Collection
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
4022798
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Aetna of IA Medicare |
$22.80
|
| Rate for Payer: Amerigroup Medicaid |
$20.19
|
| Rate for Payer: Amerigroup Medicare |
$20.20
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.99
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.30
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$20.29
|
| Rate for Payer: Oscar Health of IA Commercial |
$30.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
|
|
DOUBLE ENDED K-WIRE 0.062
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
8852331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of IA Commercial |
$15.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.30
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.75
|
| Rate for Payer: Medical Associates Commercial |
$12.75
|
| Rate for Payer: Midlands Choice Commercial |
$11.90
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
|
|
DOUBLE ENDED K-WIRE 0.062
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
8852331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of IA Commercial |
$15.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.30
|
| Rate for Payer: Aetna of IA Medicare |
$9.69
|
| Rate for Payer: Amerigroup Medicaid |
$8.58
|
| Rate for Payer: Amerigroup Medicare |
$8.58
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.50
|
| Rate for Payer: Medical Associates Commercial |
$12.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.50
|
| Rate for Payer: Midlands Choice Commercial |
$11.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.63
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$8.62
|
| Rate for Payer: Oscar Health of IA Commercial |
$12.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.75
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.03
|
|
|
doxapram 20 mg/mL 20ml MDV [VDMC]
|
Facility
|
OP
|
$198.77
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10384658
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.35 |
| Max. Negotiated Rate |
$178.89 |
| Rate for Payer: Aetna of IA Commercial |
$178.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.89
|
| Rate for Payer: Aetna of IA Medicare |
$113.30
|
| Rate for Payer: Amerigroup Medicaid |
$100.32
|
| Rate for Payer: Amerigroup Medicare |
$100.38
|
| Rate for Payer: Cash Price |
$159.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$149.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$99.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$99.35
|
| Rate for Payer: Medical Associates Commercial |
$149.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$99.38
|
| Rate for Payer: Midlands Choice Commercial |
$139.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$100.88
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$100.82
|
| Rate for Payer: Oscar Health of IA Commercial |
$149.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$149.08
|
| Rate for Payer: United Healthcare Commercial |
$178.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$117.27
|
|
|
doxapram 20 mg/mL 20ml MDV [VDMC]
|
Facility
|
IP
|
$198.77
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10384658
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$139.14 |
| Max. Negotiated Rate |
$178.89 |
| Rate for Payer: Aetna of IA Commercial |
$178.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.89
|
| Rate for Payer: Cash Price |
$159.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$149.08
|
| Rate for Payer: Medical Associates Commercial |
$149.08
|
| Rate for Payer: Midlands Choice Commercial |
$139.14
|
| Rate for Payer: United Healthcare Commercial |
$178.89
|
|
|
doxazosin 2 mg Tab [VDMC]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of IA Commercial |
$1.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.17
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.66
|
| Rate for Payer: Amerigroup Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.65
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.66
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
doxazosin 2 mg Tab [VDMC]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of IA Commercial |
$1.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.17
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
|
|
doxepin 10 mg Cap [VDMC]
|
Facility
|
IP
|
$1.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of IA Commercial |
$1.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.04
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.86
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Midlands Choice Commercial |
$0.81
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
|
|
doxepin 10 mg Cap [VDMC]
|
Facility
|
OP
|
$1.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of IA Commercial |
$1.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.04
|
| Rate for Payer: Aetna of IA Medicare |
$0.66
|
| Rate for Payer: Amerigroup Medicaid |
$0.58
|
| Rate for Payer: Amerigroup Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.57
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.58
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.58
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.68
|
|
|
doxepin 25 mg Cap [VDMC]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384867
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of IA Commercial |
$1.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.09
|
| Rate for Payer: Aetna of IA Medicare |
$0.69
|
| Rate for Payer: Amerigroup Medicaid |
$0.61
|
| Rate for Payer: Amerigroup Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.91
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.60
|
| Rate for Payer: Medical Associates Commercial |
$0.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.61
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.61
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.61
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.71
|
|
|
doxepin 25 mg Cap [VDMC]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384867
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of IA Commercial |
$1.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.09
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.91
|
| Rate for Payer: Medical Associates Commercial |
$0.91
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
|
|
DOXOrubicin 2 mg/mL 100 ml MDV [VDMC]
|
Facility
|
OP
|
$568.52
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
13339488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$284.15 |
| Max. Negotiated Rate |
$511.67 |
| Rate for Payer: Aetna of IA Commercial |
$511.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$511.67
|
| Rate for Payer: Aetna of IA Medicare |
$324.06
|
| Rate for Payer: Amerigroup Medicaid |
$286.93
|
| Rate for Payer: Amerigroup Medicare |
$287.10
|
| Rate for Payer: Cash Price |
$454.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$426.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$284.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$284.15
|
| Rate for Payer: Medical Associates Commercial |
$426.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$284.26
|
| Rate for Payer: Midlands Choice Commercial |
$397.96
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$288.52
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$288.35
|
| Rate for Payer: Oscar Health of IA Commercial |
$426.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$426.39
|
| Rate for Payer: United Healthcare Commercial |
$511.67
|
| Rate for Payer: United Healthcare Managed Medicare |
$335.43
|
|
|
DOXOrubicin 2 mg/mL 100 ml MDV [VDMC]
|
Facility
|
IP
|
$568.52
|
|
|
Service Code
|
HCPCS J9000
|
| Hospital Charge Code |
13339488
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$397.96 |
| Max. Negotiated Rate |
$511.67 |
| Rate for Payer: Aetna of IA Commercial |
$511.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$511.67
|
| Rate for Payer: Cash Price |
$454.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$426.39
|
| Rate for Payer: Medical Associates Commercial |
$426.39
|
| Rate for Payer: Midlands Choice Commercial |
$397.96
|
| Rate for Payer: United Healthcare Commercial |
$511.67
|
|
