|
digoxin 250 mcg/mL (0.25 mg/mL) 2 ML SDV Inj Sol [VDMC]
|
Facility
|
IP
|
$40.20
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
10382857
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.14 |
| Max. Negotiated Rate |
$36.18 |
| Rate for Payer: Aetna of IA Commercial |
$36.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.18
|
| Rate for Payer: Cash Price |
$32.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.15
|
| Rate for Payer: Medical Associates Commercial |
$30.15
|
| Rate for Payer: Midlands Choice Commercial |
$28.14
|
| Rate for Payer: United Healthcare Commercial |
$36.18
|
|
|
digoxin immune FAB 40 mg Inj SDV [VDMC]
|
Facility
|
IP
|
$8,898.82
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
10382928
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6,229.17 |
| Max. Negotiated Rate |
$8,008.94 |
| Rate for Payer: Aetna of IA Commercial |
$8,008.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8,008.94
|
| Rate for Payer: Cash Price |
$7,119.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,674.12
|
| Rate for Payer: Medical Associates Commercial |
$6,674.12
|
| Rate for Payer: Midlands Choice Commercial |
$6,229.17
|
| Rate for Payer: United Healthcare Commercial |
$8,008.94
|
|
|
digoxin immune FAB 40 mg Inj SDV [VDMC]
|
Facility
|
OP
|
$8,898.82
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
10382928
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,004.47 |
| Max. Negotiated Rate |
$8,008.94 |
| Rate for Payer: Aetna of IA Commercial |
$8,008.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8,008.94
|
| Rate for Payer: Aetna of IA Medicare |
$5,072.33
|
| Rate for Payer: Amerigroup Medicaid |
$5,132.84
|
| Rate for Payer: Amerigroup Medicare |
$4,044.51
|
| Rate for Payer: Cash Price |
$7,119.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,674.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,004.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5,083.01
|
| Rate for Payer: Medical Associates Commercial |
$6,674.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,004.47
|
| Rate for Payer: Midlands Choice Commercial |
$6,229.17
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,157.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,605.14
|
| Rate for Payer: United Healthcare Commercial |
$8,008.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$5,250.30
|
|
|
DILANTIN (PHENYTOIN)
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
8093930
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
|
|
DILANTIN (PHENYTOIN)
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
8093930
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.95 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Aetna of IA Medicare |
$63.27
|
| Rate for Payer: Amerigroup Medicaid |
$64.02
|
| Rate for Payer: Amerigroup Medicare |
$50.45
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$63.40
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.95
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$64.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.44
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.49
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
DILATE ESOPHAGUS 1/MULT PASS
|
Facility
|
OP
|
$1,031.00
|
|
|
Service Code
|
CPT 43450
|
| Hospital Charge Code |
7982994
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$463.95 |
| Max. Negotiated Rate |
$1,577.62 |
| Rate for Payer: Aetna of IA Commercial |
$927.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$927.90
|
| Rate for Payer: Aetna of IA Medicare |
$587.67
|
| Rate for Payer: Amerigroup Medicaid |
$594.68
|
| Rate for Payer: Amerigroup Medicare |
$468.59
|
| Rate for Payer: Cash Price |
$824.80
|
| Rate for Payer: Cash Price |
$824.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$773.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$463.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$588.91
|
| Rate for Payer: Medical Associates Commercial |
$773.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$463.95
|
| Rate for Payer: Midlands Choice Commercial |
$721.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$597.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$533.54
|
| Rate for Payer: United Healthcare Commercial |
$927.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$608.29
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,432.18
|
| Rate for Payer: Wellmark IA PPO |
$1,577.62
|
|
|
DILATE ESOPHAGUS 1/MULT PASS
|
Facility
|
IP
|
$1,031.00
|
|
|
Service Code
|
CPT 43450
|
| Hospital Charge Code |
7982994
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$721.70 |
| Max. Negotiated Rate |
$927.90 |
| Rate for Payer: Aetna of IA Commercial |
$927.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$927.90
|
| Rate for Payer: Cash Price |
$824.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$773.25
|
| Rate for Payer: Medical Associates Commercial |
$773.25
|
| Rate for Payer: Midlands Choice Commercial |
$721.70
|
| Rate for Payer: United Healthcare Commercial |
$927.90
|
|
|
DILATE URETHRA STRICTURE
|
Facility
|
IP
|
$368.00
|
|
|
Service Code
|
CPT 53600
|
| Hospital Charge Code |
7982993
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$257.60 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna of IA Commercial |
$331.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$331.20
|
| Rate for Payer: Cash Price |
$294.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$276.00
|
| Rate for Payer: Medical Associates Commercial |
$276.00
|
| Rate for Payer: Midlands Choice Commercial |
$257.60
|
| Rate for Payer: United Healthcare Commercial |
$331.20
|
|
|
DILATE URETHRA STRICTURE
|
Facility
|
OP
|
$368.00
|
|
|
Service Code
|
CPT 53600
|
| Hospital Charge Code |
7982993
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.60 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna of IA Commercial |
$331.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$331.20
|
| Rate for Payer: Aetna of IA Medicare |
$209.76
|
| Rate for Payer: Amerigroup Medicaid |
$212.26
|
| Rate for Payer: Amerigroup Medicare |
$167.26
|
| Rate for Payer: Cash Price |
$294.40
|
| Rate for Payer: Cash Price |
$294.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$276.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$165.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$210.20
|
| Rate for Payer: Medical Associates Commercial |
$276.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$165.60
|
| Rate for Payer: Midlands Choice Commercial |
$257.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$213.29
|
| Rate for Payer: Partners Health Alliance Commercial |
$190.44
|
| Rate for Payer: United Healthcare Commercial |
$331.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$217.12
|
| Rate for Payer: Wellmark IA HMO WHPI |
$243.19
|
| Rate for Payer: Wellmark IA PPO |
$267.88
|
|
|
DILATION OF URETHRA
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
CPT 53661
|
| Hospital Charge Code |
7982991
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Aetna of IA Commercial |
$165.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$165.60
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$138.00
|
| Rate for Payer: Medical Associates Commercial |
$138.00
|
| Rate for Payer: Midlands Choice Commercial |
$128.80
|
| Rate for Payer: United Healthcare Commercial |
$165.60
|
|
|
DILATION OF URETHRA
|
Facility
|
IP
|
$221.00
|
|
|
Service Code
|
CPT 53660
|
| Hospital Charge Code |
7982992
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$154.70 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna of IA Commercial |
$198.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$198.90
|
| Rate for Payer: Cash Price |
$176.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$165.75
|
| Rate for Payer: Medical Associates Commercial |
$165.75
|
| Rate for Payer: Midlands Choice Commercial |
$154.70
|
| Rate for Payer: United Healthcare Commercial |
$198.90
|
|
|
DILATION OF URETHRA
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
CPT 53660
|
| Hospital Charge Code |
7982992
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$99.45 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna of IA Commercial |
$198.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$198.90
|
| Rate for Payer: Aetna of IA Medicare |
$125.97
|
| Rate for Payer: Amerigroup Medicaid |
$127.47
|
| Rate for Payer: Amerigroup Medicare |
$100.44
|
| Rate for Payer: Cash Price |
$176.80
|
| Rate for Payer: Cash Price |
$176.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$165.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$99.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$126.24
|
| Rate for Payer: Medical Associates Commercial |
$165.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$99.45
|
| Rate for Payer: Midlands Choice Commercial |
$154.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$128.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$114.37
|
| Rate for Payer: United Healthcare Commercial |
$198.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$130.39
|
| Rate for Payer: Wellmark IA HMO WHPI |
$243.19
|
| Rate for Payer: Wellmark IA PPO |
$267.88
|
|
|
DILATION OF URETHRA
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
CPT 53661
|
| Hospital Charge Code |
7982991
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$82.80 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna of IA Commercial |
$165.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$165.60
|
| Rate for Payer: Aetna of IA Medicare |
$104.88
|
| Rate for Payer: Amerigroup Medicaid |
$106.13
|
| Rate for Payer: Amerigroup Medicare |
$83.63
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$138.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$82.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$105.10
|
| Rate for Payer: Medical Associates Commercial |
$138.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$82.80
|
| Rate for Payer: Midlands Choice Commercial |
$128.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$106.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$95.22
|
| Rate for Payer: United Healthcare Commercial |
$165.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$108.56
|
| Rate for Payer: Wellmark IA HMO WHPI |
$243.19
|
| Rate for Payer: Wellmark IA PPO |
$267.88
|
|
|
diltiazem 120 mg/24 hours ERCap [VDMC]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383064
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna of IA Commercial |
$1.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.96
|
| Rate for Payer: Aetna of IA Medicare |
$1.24
|
| Rate for Payer: Amerigroup Medicaid |
$1.26
|
| Rate for Payer: Amerigroup Medicare |
$0.99
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.63
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.24
|
| Rate for Payer: Medical Associates Commercial |
$1.63
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.98
|
| Rate for Payer: Midlands Choice Commercial |
$1.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.13
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.28
|
|
|
diltiazem 120 mg/24 hours ERCap [VDMC]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383064
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna of IA Commercial |
$1.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.96
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.63
|
| Rate for Payer: Medical Associates Commercial |
$1.63
|
| Rate for Payer: Midlands Choice Commercial |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
|
|
diltiazem 180 mg/24 hours ERCap [VDMC]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| 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 |
$1.63
|
| Rate for Payer: Medical Associates Commercial |
$1.63
|
| Rate for Payer: Midlands Choice Commercial |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
|
|
diltiazem 180 mg/24 hours ERCap [VDMC]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| 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 |
$1.24
|
| 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 |
$1.63
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.24
|
| Rate for Payer: Medical Associates Commercial |
$1.63
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.98
|
| Rate for Payer: Midlands Choice Commercial |
$1.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.26
|
| 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
|
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
|
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
|
|
|
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
|
|
|
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
|
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 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
|
|
