|
donepezil 10 mg Tab [VDMC]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384451
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of IA Commercial |
$1.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.18
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| 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 |
$0.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.75
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.68
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
donepezil 10 mg Tab [VDMC]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384451
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of IA Commercial |
$1.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.18
|
| 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 |
$1.18
|
|
|
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 |
$22.50 |
| 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 |
$28.84
|
| Rate for Payer: Amerigroup Medicare |
$22.72
|
| 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 |
$22.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.56
|
| Rate for Payer: Medical Associates Commercial |
$37.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.50
|
| Rate for Payer: Midlands Choice Commercial |
$35.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$28.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$25.88
|
| 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
|
$76.10
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
10430775
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.24 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$68.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.49
|
| Rate for Payer: Aetna of IA Medicare |
$43.38
|
| Rate for Payer: Amerigroup Medicaid |
$43.89
|
| Rate for Payer: Amerigroup Medicare |
$34.59
|
| Rate for Payer: Cash Price |
$60.88
|
| Rate for Payer: Cash Price |
$60.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$34.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$43.47
|
| Rate for Payer: Medical Associates Commercial |
$57.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$34.24
|
| Rate for Payer: Midlands Choice Commercial |
$53.27
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$44.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.38
|
| Rate for Payer: United Healthcare Commercial |
$68.49
|
| Rate for Payer: United Healthcare Managed Medicare |
$44.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
dopamine/dextrose 5% 400MG/250ML [VDMC]
|
Facility
|
IP
|
$76.10
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
10430775
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.27 |
| Max. Negotiated Rate |
$68.49 |
| Rate for Payer: Aetna of IA Commercial |
$68.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.49
|
| Rate for Payer: Cash Price |
$60.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.08
|
| Rate for Payer: Medical Associates Commercial |
$57.08
|
| Rate for Payer: Midlands Choice Commercial |
$53.27
|
| Rate for Payer: United Healthcare Commercial |
$68.49
|
|
|
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 |
$23.51 |
| 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 |
$30.13
|
| Rate for Payer: Amerigroup Medicare |
$23.74
|
| 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 |
$23.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$29.84
|
| Rate for Payer: Medical Associates Commercial |
$39.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.51
|
| Rate for Payer: Midlands Choice Commercial |
$36.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$27.03
|
| Rate for Payer: United Healthcare Commercial |
$47.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.82
|
|
|
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-timolol Ophth 22.3mg-6.8mg Sol [VDMC]
|
Facility
|
OP
|
$45.76
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384593
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.59 |
| Max. Negotiated Rate |
$41.18 |
| Rate for Payer: Aetna of IA Commercial |
$41.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$41.18
|
| Rate for Payer: Aetna of IA Medicare |
$26.08
|
| Rate for Payer: Amerigroup Medicaid |
$26.39
|
| Rate for Payer: Amerigroup Medicare |
$20.80
|
| Rate for Payer: Cash Price |
$36.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$34.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.14
|
| Rate for Payer: Medical Associates Commercial |
$34.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.59
|
| Rate for Payer: Midlands Choice Commercial |
$32.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.68
|
| Rate for Payer: United Healthcare Commercial |
$41.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$27.00
|
|
|
dorzolamide-timolol Ophth 22.3mg-6.8mg Sol [VDMC]
|
Facility
|
IP
|
$45.76
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384593
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.03 |
| Max. Negotiated Rate |
$41.18 |
| Rate for Payer: Aetna of IA Commercial |
$41.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$41.18
|
| Rate for Payer: Cash Price |
$36.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$34.32
|
| Rate for Payer: Medical Associates Commercial |
$34.32
|
| Rate for Payer: Midlands Choice Commercial |
$32.03
|
| Rate for Payer: United Healthcare Commercial |
$41.18
|
|
|
DOT/NON-DOT Urine Drug Collection and Send Out
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
7845714
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$12.05 |
| 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 |
$23.07
|
| Rate for Payer: Amerigroup Medicare |
$18.18
|
| Rate for Payer: Cash Price |
$32.00
|
| 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 |
$18.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.85
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.70
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
| Rate for Payer: Wellmark IA HMO WHPI |
$12.05
|
| Rate for Payer: Wellmark IA PPO |
$13.28
|
|
|
DOT/NON-DOT Urine Drug Collection and Send Out
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
7845714
|
|
Hospital Revenue Code
|
309
|
| 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 |
$12.05 |
| 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 |
$23.07
|
| Rate for Payer: Amerigroup Medicare |
$18.18
|
| Rate for Payer: Cash Price |
$32.00
|
| 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 |
$18.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.85
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.70
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
| Rate for Payer: Wellmark IA HMO WHPI |
$12.05
|
| Rate for Payer: Wellmark IA PPO |
$13.28
|
|
|
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
|
|
|
DOUBLE ENDED K-WIRE 0.062
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8852331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7.65 |
| 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 |
$9.81
|
| Rate for Payer: Amerigroup Medicare |
$7.73
|
| 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 |
$7.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.71
|
| Rate for Payer: Medical Associates Commercial |
$12.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.65
|
| Rate for Payer: Midlands Choice Commercial |
$11.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.80
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.03
|
|
|
DOUBLE ENDED K-WIRE 0.062
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS 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
|
|
|
doxazosin 2 mg Tab [VDMC]
|
Facility
|
OP
|
$3.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Aetna of IA Commercial |
$3.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.03
|
| Rate for Payer: Aetna of IA Medicare |
$1.92
|
| Rate for Payer: Amerigroup Medicaid |
$1.94
|
| Rate for Payer: Amerigroup Medicare |
$1.53
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.53
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.92
|
| Rate for Payer: Medical Associates Commercial |
$2.53
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.52
|
| Rate for Payer: Midlands Choice Commercial |
$2.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.99
|
|
|
doxazosin 2 mg Tab [VDMC]
|
Facility
|
IP
|
$3.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Aetna of IA Commercial |
$3.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.03
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.53
|
| Rate for Payer: Medical Associates Commercial |
$2.53
|
| Rate for Payer: Midlands Choice Commercial |
$2.36
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
|
|
doxepin 10 mg Cap [VDMC]
|
Facility
|
OP
|
$1.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of IA Commercial |
$1.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.03
|
| Rate for Payer: Aetna of IA Medicare |
$0.65
|
| Rate for Payer: Amerigroup Medicaid |
$0.66
|
| Rate for Payer: Amerigroup Medicare |
$0.52
|
| 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 |
$0.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.52
|
| Rate for Payer: Midlands Choice Commercial |
$0.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.59
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.68
|
|
|
doxepin 10 mg Cap [VDMC]
|
Facility
|
IP
|
$1.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of IA Commercial |
$1.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.03
|
| 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 |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
|
|
doxepin 25 mg Cap [VDMC]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384867
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| 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 |
$0.90
|
| Rate for Payer: Medical Associates Commercial |
$0.90
|
| Rate for Payer: Midlands Choice Commercial |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
|
|
doxepin 25 mg Cap [VDMC]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10384867
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| 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 |
$0.70
|
| Rate for Payer: Amerigroup Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.69
|
| Rate for Payer: Medical Associates Commercial |
$0.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.54
|
| Rate for Payer: Midlands Choice Commercial |
$0.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.62
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.71
|
|
|
doxycycline 100 mg SDV Inj [VDMC]
|
Facility
|
OP
|
$61.47
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10384936
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.66 |
| Max. Negotiated Rate |
$55.32 |
| Rate for Payer: Aetna of IA Commercial |
$55.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.32
|
| Rate for Payer: Aetna of IA Medicare |
$35.04
|
| Rate for Payer: Amerigroup Medicaid |
$35.45
|
| Rate for Payer: Amerigroup Medicare |
$27.94
|
| Rate for Payer: Cash Price |
$49.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.11
|
| Rate for Payer: Medical Associates Commercial |
$46.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.66
|
| Rate for Payer: Midlands Choice Commercial |
$43.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.81
|
| Rate for Payer: United Healthcare Commercial |
$55.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.27
|
|
|
doxycycline 100 mg SDV Inj [VDMC]
|
Facility
|
IP
|
$61.47
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10384936
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$43.03 |
| Max. Negotiated Rate |
$55.32 |
| Rate for Payer: Aetna of IA Commercial |
$55.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.32
|
| Rate for Payer: Cash Price |
$49.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.10
|
| Rate for Payer: Medical Associates Commercial |
$46.10
|
| Rate for Payer: Midlands Choice Commercial |
$43.03
|
| Rate for Payer: United Healthcare Commercial |
$55.32
|
|
|
doxycycline hyclate 100 mg Tab [VDMC]
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
12634860
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of IA Commercial |
$1.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.21
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.01
|
| Rate for Payer: Medical Associates Commercial |
$1.01
|
| Rate for Payer: Midlands Choice Commercial |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
