|
EPIDRM A-GRFT FACE/NCK/HF/G
|
Facility
|
OP
|
$1,408.00
|
|
|
Service Code
|
CPT 15115
|
| Hospital Charge Code |
7982937
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$633.60 |
| Max. Negotiated Rate |
$1,267.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,267.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,267.20
|
| Rate for Payer: Aetna of IA Medicare |
$802.56
|
| Rate for Payer: Amerigroup Medicaid |
$812.13
|
| Rate for Payer: Amerigroup Medicare |
$639.94
|
| Rate for Payer: Cash Price |
$1,126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,056.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$633.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$804.25
|
| Rate for Payer: Medical Associates Commercial |
$1,056.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$633.60
|
| Rate for Payer: Midlands Choice Commercial |
$985.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$816.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$728.64
|
| Rate for Payer: United Healthcare Commercial |
$1,267.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$830.72
|
|
|
EPIDURAL BLOCK-CERVICAL/THORACIC SPINE
|
Professional
|
Both
|
$554.00
|
|
|
Service Code
|
CPT 62320
|
| Hospital Charge Code |
8101309
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$249.23 |
| Max. Negotiated Rate |
$415.50 |
| Rate for Payer: Cash Price |
$443.20
|
| Rate for Payer: Cash Price |
$443.20
|
| Rate for Payer: Medical Associates Commercial |
$415.50
|
| Rate for Payer: Midlands Choice Commercial |
$387.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$415.50
|
| Rate for Payer: United Healthcare Commercial |
$249.23
|
|
|
EPINEPHrine 0.3 mg Kit [VDMC]
|
Facility
|
OP
|
$544.30
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
11223910
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$244.94 |
| Max. Negotiated Rate |
$489.87 |
| Rate for Payer: Aetna of IA Commercial |
$489.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$489.87
|
| Rate for Payer: Aetna of IA Medicare |
$310.25
|
| Rate for Payer: Amerigroup Medicaid |
$313.95
|
| Rate for Payer: Amerigroup Medicare |
$247.38
|
| Rate for Payer: Cash Price |
$435.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$408.23
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$244.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$310.90
|
| Rate for Payer: Medical Associates Commercial |
$408.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$244.94
|
| Rate for Payer: Midlands Choice Commercial |
$381.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$315.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$281.68
|
| Rate for Payer: United Healthcare Commercial |
$489.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$321.14
|
|
|
EPINEPHrine 0.3 mg Kit [VDMC]
|
Facility
|
IP
|
$544.30
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
11223910
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$381.01 |
| Max. Negotiated Rate |
$489.87 |
| Rate for Payer: Aetna of IA Commercial |
$489.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$489.87
|
| Rate for Payer: Cash Price |
$435.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$408.23
|
| Rate for Payer: Medical Associates Commercial |
$408.23
|
| Rate for Payer: Midlands Choice Commercial |
$381.01
|
| Rate for Payer: United Healthcare Commercial |
$489.87
|
|
|
EPINEPHrine 0.3mL Syringe SDV [VDMC]
|
Facility
|
IP
|
$71.79
|
|
|
Service Code
|
NDC 99999-9061-00
|
| Hospital Charge Code |
12362767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.25 |
| Max. Negotiated Rate |
$64.61 |
| Rate for Payer: Aetna of IA Commercial |
$64.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.61
|
| Rate for Payer: Cash Price |
$57.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.84
|
| Rate for Payer: Medical Associates Commercial |
$53.84
|
| Rate for Payer: Midlands Choice Commercial |
$50.25
|
| Rate for Payer: United Healthcare Commercial |
$64.61
|
|
|
EPINEPHrine 0.3mL Syringe SDV [VDMC]
|
Facility
|
OP
|
$71.79
|
|
|
Service Code
|
NDC 99999-9061-00
|
| Hospital Charge Code |
12362767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$64.61 |
| Rate for Payer: Aetna of IA Commercial |
$64.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.61
|
| Rate for Payer: Aetna of IA Medicare |
$40.92
|
| Rate for Payer: Amerigroup Medicaid |
$41.41
|
| Rate for Payer: Amerigroup Medicare |
$32.63
|
| Rate for Payer: Cash Price |
$57.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$41.01
|
| Rate for Payer: Medical Associates Commercial |
$53.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.30
|
| Rate for Payer: Midlands Choice Commercial |
$50.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$37.15
|
| Rate for Payer: United Healthcare Commercial |
$64.61
|
| Rate for Payer: United Healthcare Managed Medicare |
$42.36
|
|
|
EPINEPHrine 1 mg/mL 1ml vial SDV [VDMC]
|
Facility
|
OP
|
$108.27
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
11219984
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$97.44 |
| Rate for Payer: Aetna of IA Commercial |
$97.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.44
|
| Rate for Payer: Aetna of IA Medicare |
$61.71
|
| Rate for Payer: Amerigroup Medicaid |
$62.45
|
| Rate for Payer: Amerigroup Medicare |
$49.21
|
| Rate for Payer: Cash Price |
$86.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$48.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$61.84
|
| Rate for Payer: Medical Associates Commercial |
$81.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$48.72
|
| Rate for Payer: Midlands Choice Commercial |
$75.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$62.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.03
|
| Rate for Payer: United Healthcare Commercial |
$97.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.88
|
|
|
EPINEPHrine 1 mg/mL 1ml vial SDV [VDMC]
|
Facility
|
IP
|
$108.27
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
11219984
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$75.79 |
| Max. Negotiated Rate |
$97.44 |
| Rate for Payer: Aetna of IA Commercial |
$97.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.44
|
| Rate for Payer: Cash Price |
$86.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.20
|
| Rate for Payer: Medical Associates Commercial |
$81.20
|
| Rate for Payer: Midlands Choice Commercial |
$75.79
|
| Rate for Payer: United Healthcare Commercial |
$97.44
|
|
|
EPINEPHrine 1 mg/mL 30ml Inj MDV [VDMC]
|
Facility
|
IP
|
$645.48
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386241
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$451.84 |
| Max. Negotiated Rate |
$580.93 |
| Rate for Payer: Aetna of IA Commercial |
$580.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$580.93
|
| Rate for Payer: Cash Price |
$516.38
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$484.11
|
| Rate for Payer: Medical Associates Commercial |
$484.11
|
| Rate for Payer: Midlands Choice Commercial |
$451.84
|
| Rate for Payer: United Healthcare Commercial |
$580.93
|
|
|
EPINEPHrine 1 mg/mL 30ml Inj MDV [VDMC]
|
Facility
|
OP
|
$645.48
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386241
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$290.47 |
| Max. Negotiated Rate |
$580.93 |
| Rate for Payer: Aetna of IA Commercial |
$580.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$580.93
|
| Rate for Payer: Aetna of IA Medicare |
$367.92
|
| Rate for Payer: Amerigroup Medicaid |
$372.31
|
| Rate for Payer: Amerigroup Medicare |
$293.37
|
| Rate for Payer: Cash Price |
$516.38
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$484.11
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$290.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$368.70
|
| Rate for Payer: Medical Associates Commercial |
$484.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$290.47
|
| Rate for Payer: Midlands Choice Commercial |
$451.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$374.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$334.04
|
| Rate for Payer: United Healthcare Commercial |
$580.93
|
| Rate for Payer: United Healthcare Managed Medicare |
$380.83
|
|
|
EPINEPHrine Emergency syringe 0.1 mg/mL 10ml Inj SDV [VDMC]
|
Facility
|
OP
|
$54.96
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$24.73 |
| Max. Negotiated Rate |
$49.46 |
| Rate for Payer: Aetna of IA Commercial |
$49.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.46
|
| Rate for Payer: Aetna of IA Medicare |
$31.32
|
| Rate for Payer: Amerigroup Medicaid |
$31.70
|
| Rate for Payer: Amerigroup Medicare |
$24.98
|
| Rate for Payer: Cash Price |
$43.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.39
|
| Rate for Payer: Medical Associates Commercial |
$41.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.73
|
| Rate for Payer: Midlands Choice Commercial |
$38.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$28.44
|
| Rate for Payer: United Healthcare Commercial |
$49.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$32.42
|
|
|
EPINEPHrine Emergency syringe 0.1 mg/mL 10ml Inj SDV [VDMC]
|
Facility
|
IP
|
$54.96
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.47 |
| Max. Negotiated Rate |
$49.46 |
| Rate for Payer: Aetna of IA Commercial |
$49.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.46
|
| Rate for Payer: Cash Price |
$43.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.22
|
| Rate for Payer: Medical Associates Commercial |
$41.22
|
| Rate for Payer: Midlands Choice Commercial |
$38.47
|
| Rate for Payer: United Healthcare Commercial |
$49.46
|
|
|
EPINEPHrine ( Eye Surgery )1 mg/mL 0.3ml Inj Sol [VDMC]
|
Facility
|
OP
|
$104.97
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10607748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.24 |
| Max. Negotiated Rate |
$94.47 |
| Rate for Payer: Aetna of IA Commercial |
$94.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.47
|
| Rate for Payer: Aetna of IA Medicare |
$59.83
|
| Rate for Payer: Amerigroup Medicaid |
$60.55
|
| Rate for Payer: Amerigroup Medicare |
$47.71
|
| Rate for Payer: Cash Price |
$83.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.73
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$47.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.96
|
| Rate for Payer: Medical Associates Commercial |
$78.73
|
| Rate for Payer: Medical Associates Managed Medicare |
$47.24
|
| Rate for Payer: Midlands Choice Commercial |
$73.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$54.32
|
| Rate for Payer: United Healthcare Commercial |
$94.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.93
|
|
|
EPINEPHrine ( Eye Surgery )1 mg/mL 0.3ml Inj Sol [VDMC]
|
Facility
|
IP
|
$104.97
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10607748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$73.48 |
| Max. Negotiated Rate |
$94.47 |
| Rate for Payer: Aetna of IA Commercial |
$94.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.47
|
| Rate for Payer: Cash Price |
$83.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.73
|
| Rate for Payer: Medical Associates Commercial |
$78.73
|
| Rate for Payer: Midlands Choice Commercial |
$73.48
|
| Rate for Payer: United Healthcare Commercial |
$94.47
|
|
|
EPINEPHrine (PEN JR) 0.15 mg Inj kit SDV [VDMC]
|
Facility
|
IP
|
$545.14
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$381.60 |
| Max. Negotiated Rate |
$490.63 |
| Rate for Payer: Aetna of IA Commercial |
$490.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$490.63
|
| Rate for Payer: Cash Price |
$436.11
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$408.86
|
| Rate for Payer: Medical Associates Commercial |
$408.86
|
| Rate for Payer: Midlands Choice Commercial |
$381.60
|
| Rate for Payer: United Healthcare Commercial |
$490.63
|
|
|
EPINEPHrine (PEN JR) 0.15 mg Inj kit SDV [VDMC]
|
Facility
|
OP
|
$545.14
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$245.31 |
| Max. Negotiated Rate |
$490.63 |
| Rate for Payer: Aetna of IA Commercial |
$490.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$490.63
|
| Rate for Payer: Aetna of IA Medicare |
$310.73
|
| Rate for Payer: Amerigroup Medicaid |
$314.44
|
| Rate for Payer: Amerigroup Medicare |
$247.77
|
| Rate for Payer: Cash Price |
$436.11
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$408.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$245.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$311.38
|
| Rate for Payer: Medical Associates Commercial |
$408.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$245.31
|
| Rate for Payer: Midlands Choice Commercial |
$381.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$315.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$282.11
|
| Rate for Payer: United Healthcare Commercial |
$490.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$321.63
|
|
|
epoetin alfa-epbx 10,000 units/mL 1ml SDV preservative-free Sol[VDMC]
|
Facility
|
OP
|
$373.35
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
24628846
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$168.01 |
| Max. Negotiated Rate |
$336.01 |
| Rate for Payer: Aetna of IA Commercial |
$336.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.01
|
| Rate for Payer: Aetna of IA Medicare |
$212.81
|
| Rate for Payer: Amerigroup Medicaid |
$215.35
|
| Rate for Payer: Amerigroup Medicare |
$169.69
|
| Rate for Payer: Cash Price |
$298.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$168.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$213.26
|
| Rate for Payer: Medical Associates Commercial |
$280.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$168.01
|
| Rate for Payer: Midlands Choice Commercial |
$261.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$216.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$193.21
|
| Rate for Payer: United Healthcare Commercial |
$336.01
|
| Rate for Payer: United Healthcare Managed Medicare |
$220.28
|
|
|
epoetin alfa-epbx 10,000 units/mL 1ml SDV preservative-free Sol[VDMC]
|
Facility
|
IP
|
$373.35
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
24628846
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$261.34 |
| Max. Negotiated Rate |
$336.01 |
| Rate for Payer: Aetna of IA Commercial |
$336.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.01
|
| Rate for Payer: Cash Price |
$298.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.01
|
| Rate for Payer: Medical Associates Commercial |
$280.01
|
| Rate for Payer: Midlands Choice Commercial |
$261.34
|
| Rate for Payer: United Healthcare Commercial |
$336.01
|
|
|
Epstein Barr Virus Profile DMCL
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
8519173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$51.30 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$65.76
|
| Rate for Payer: Amerigroup Medicare |
$51.81
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.12
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.30
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$58.99
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
|
|
Epstein Barr Virus Profile DMCL
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
8519173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
eptinezumab jjmr 100 mg/mL Sol [VDMC]
|
Facility
|
IP
|
$3,876.30
|
|
|
Service Code
|
HCPCS J3032
|
| Hospital Charge Code |
28477766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,713.41 |
| Max. Negotiated Rate |
$3,488.67 |
| Rate for Payer: Aetna of IA Commercial |
$3,488.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,488.67
|
| Rate for Payer: Cash Price |
$3,101.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,907.22
|
| Rate for Payer: Medical Associates Commercial |
$2,907.22
|
| Rate for Payer: Midlands Choice Commercial |
$2,713.41
|
| Rate for Payer: United Healthcare Commercial |
$3,488.67
|
|
|
eptinezumab jjmr 100 mg/mL Sol [VDMC]
|
Facility
|
OP
|
$3,876.30
|
|
|
Service Code
|
HCPCS J3032
|
| Hospital Charge Code |
28477766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,744.34 |
| Max. Negotiated Rate |
$3,488.67 |
| Rate for Payer: Aetna of IA Commercial |
$3,488.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,488.67
|
| Rate for Payer: Aetna of IA Medicare |
$2,209.49
|
| Rate for Payer: Amerigroup Medicaid |
$2,235.85
|
| Rate for Payer: Amerigroup Medicare |
$1,761.78
|
| Rate for Payer: Cash Price |
$3,101.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,907.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,744.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,214.14
|
| Rate for Payer: Medical Associates Commercial |
$2,907.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,744.34
|
| Rate for Payer: Midlands Choice Commercial |
$2,713.41
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,246.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,005.99
|
| Rate for Payer: United Healthcare Commercial |
$3,488.67
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,287.02
|
|
|
ergocalciferol 50,000 intl units Cap [VDMC]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10386848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of IA Commercial |
$1.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.35
|
| Rate for Payer: Aetna of IA Medicare |
$0.85
|
| Rate for Payer: Amerigroup Medicaid |
$0.86
|
| Rate for Payer: Amerigroup Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.86
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.67
|
| Rate for Payer: Midlands Choice Commercial |
$1.05
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.78
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.88
|
|
|
ergocalciferol 50,000 intl units Cap [VDMC]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10386848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of IA Commercial |
$1.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.35
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
|
|
ertapenem 1 g Inj SDV [VDMC]
|
Facility
|
IP
|
$81.70
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
10386917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$57.19 |
| Max. Negotiated Rate |
$73.53 |
| Rate for Payer: Aetna of IA Commercial |
$73.53
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.53
|
| Rate for Payer: Cash Price |
$65.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.27
|
| Rate for Payer: Medical Associates Commercial |
$61.27
|
| Rate for Payer: Midlands Choice Commercial |
$57.19
|
| Rate for Payer: United Healthcare Commercial |
$73.53
|
|
