|
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
|
OP
|
$545.14
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$201.36 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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
|
|
|
EPISTAXIS WITH MCC
|
Facility
|
IP
|
$14,919.20
|
|
|
Service Code
|
MSDRG 150
|
| Min. Negotiated Rate |
$14,702.97 |
| Max. Negotiated Rate |
$14,919.20 |
| Rate for Payer: Amerigroup Medicaid |
$14,847.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14,702.97
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14,919.20
|
|
|
EPISTAXIS WITHOUT MCC
|
Facility
|
IP
|
$4,561.33
|
|
|
Service Code
|
MSDRG 151
|
| Min. Negotiated Rate |
$4,495.22 |
| Max. Negotiated Rate |
$4,561.33 |
| Rate for Payer: Amerigroup Medicaid |
$4,539.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,495.22
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,561.33
|
|
|
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
|
|
|
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
|
|
|
Epstein Barr Virus Profile DMCL
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
8519173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$41.83 |
| 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: 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 |
$59.00
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
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
|
OP
|
$81.70
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
10386917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.76 |
| 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: Aetna of IA Medicare |
$46.57
|
| Rate for Payer: Amerigroup Medicaid |
$47.12
|
| Rate for Payer: Amerigroup Medicare |
$37.13
|
| Rate for Payer: Cash Price |
$65.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$36.76
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$46.67
|
| Rate for Payer: Medical Associates Commercial |
$61.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$36.76
|
| Rate for Payer: Midlands Choice Commercial |
$57.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$47.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.28
|
| Rate for Payer: United Healthcare Commercial |
$73.53
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.20
|
|
|
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 |
$61.28
|
| Rate for Payer: Medical Associates Commercial |
$61.28
|
| Rate for Payer: Midlands Choice Commercial |
$57.19
|
| Rate for Payer: United Healthcare Commercial |
$73.53
|
|
|
erythromycin 500 mg DR Tab [VDMC]
|
Facility
|
IP
|
$25.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
28180188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.62 |
| Max. Negotiated Rate |
$22.66 |
| Rate for Payer: Aetna of IA Commercial |
$22.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.66
|
| Rate for Payer: Cash Price |
$20.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.88
|
| Rate for Payer: Medical Associates Commercial |
$18.88
|
| Rate for Payer: Midlands Choice Commercial |
$17.62
|
| Rate for Payer: United Healthcare Commercial |
$22.66
|
|
|
erythromycin 500 mg DR Tab [VDMC]
|
Facility
|
OP
|
$25.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
28180188
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$22.66 |
| Rate for Payer: Aetna of IA Commercial |
$22.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.66
|
| Rate for Payer: Aetna of IA Medicare |
$14.35
|
| Rate for Payer: Amerigroup Medicaid |
$14.52
|
| Rate for Payer: Amerigroup Medicare |
$11.44
|
| Rate for Payer: Cash Price |
$20.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.33
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.38
|
| Rate for Payer: Medical Associates Commercial |
$18.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.33
|
| Rate for Payer: Midlands Choice Commercial |
$17.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.03
|
| Rate for Payer: United Healthcare Commercial |
$22.66
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.85
|
|
|
erythromycin ophthalmic 0.5% Oint. 3.5gm [VDMC]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
18197658
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Aetna of IA Medicare |
$37.05
|
| Rate for Payer: Amerigroup Medicaid |
$37.49
|
| Rate for Payer: Amerigroup Medicare |
$29.54
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.13
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.25
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.64
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.35
|
|
|
erythromycin ophthalmic 0.5% Oint. 3.5gm [VDMC]
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
18197658
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
|
|
Erythropoietin Level DMCL
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
8037840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
|
|
Erythropoietin Level DMCL
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
8037840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$61.68 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Aetna of IA Medicare |
$102.03
|
| Rate for Payer: Amerigroup Medicaid |
$103.25
|
| Rate for Payer: Amerigroup Medicare |
$81.36
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$80.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.24
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$80.55
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$103.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$92.63
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$105.61
|
| Rate for Payer: Wellmark IA HMO WHPI |
$61.68
|
| Rate for Payer: Wellmark IA PPO |
$67.95
|
|
|
escitalopram 10 mg Tab [VDMC]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10387189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna of IA Commercial |
$1.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.41
|
| Rate for Payer: Aetna of IA Medicare |
$0.89
|
| Rate for Payer: Amerigroup Medicaid |
$0.90
|
| Rate for Payer: Amerigroup Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.17
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$1.17
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.70
|
| Rate for Payer: Midlands Choice Commercial |
$1.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.81
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.92
|
|
|
escitalopram 10 mg Tab [VDMC]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10387189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna of IA Commercial |
$1.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.41
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.17
|
| Rate for Payer: Medical Associates Commercial |
$1.17
|
| Rate for Payer: Midlands Choice Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
|
|
esketamine 56 mg/2 Nasal Spray [VDMC]
|
Facility
|
IP
|
$3,172.96
|
|
|
Service Code
|
HCPCS S0013
|
| Hospital Charge Code |
18384531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,221.07 |
| Max. Negotiated Rate |
$2,855.66 |
| Rate for Payer: Aetna of IA Commercial |
$2,855.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,855.66
|
| Rate for Payer: Cash Price |
$2,538.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,379.72
|
| Rate for Payer: Medical Associates Commercial |
$2,379.72
|
| Rate for Payer: Midlands Choice Commercial |
$2,221.07
|
| Rate for Payer: United Healthcare Commercial |
$2,855.66
|
|
|
esketamine 56 mg/2 Nasal Spray [VDMC]
|
Facility
|
OP
|
$3,172.96
|
|
|
Service Code
|
HCPCS S0013
|
| Hospital Charge Code |
18384531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,427.83 |
| Max. Negotiated Rate |
$2,855.66 |
| Rate for Payer: Aetna of IA Commercial |
$2,855.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,855.66
|
| Rate for Payer: Aetna of IA Medicare |
$1,808.59
|
| Rate for Payer: Amerigroup Medicaid |
$1,830.16
|
| Rate for Payer: Amerigroup Medicare |
$1,442.11
|
| Rate for Payer: Cash Price |
$2,538.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,379.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,427.83
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,812.39
|
| Rate for Payer: Medical Associates Commercial |
$2,379.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,427.83
|
| Rate for Payer: Midlands Choice Commercial |
$2,221.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,839.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,642.01
|
| Rate for Payer: United Healthcare Commercial |
$2,855.66
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,872.05
|
|
