|
furosemide 10 mg/mL Inj Sol 10mL SDV [VDMC]
|
Facility
|
IP
|
$26.40
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
10391145
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$23.76 |
| Rate for Payer: Aetna of IA Commercial |
$23.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.76
|
| Rate for Payer: Cash Price |
$21.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.80
|
| Rate for Payer: Medical Associates Commercial |
$19.80
|
| Rate for Payer: Midlands Choice Commercial |
$18.48
|
| Rate for Payer: United Healthcare Commercial |
$23.76
|
|
|
furosemide 10 mg/mL Inj Sol 10mL SDV [VDMC]
|
Facility
|
OP
|
$26.40
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
10391145
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.19 |
| Max. Negotiated Rate |
$23.76 |
| Rate for Payer: Aetna of IA Commercial |
$23.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.76
|
| Rate for Payer: Aetna of IA Medicare |
$15.05
|
| Rate for Payer: Amerigroup Medicaid |
$13.32
|
| Rate for Payer: Amerigroup Medicare |
$13.33
|
| Rate for Payer: Cash Price |
$21.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.19
|
| Rate for Payer: Medical Associates Commercial |
$19.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.20
|
| Rate for Payer: Midlands Choice Commercial |
$18.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.40
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$13.39
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.80
|
| Rate for Payer: United Healthcare Commercial |
$23.76
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.58
|
|
|
furosemide 10 mg/mL Inj Sol 2 mL SDV [VDMC]
|
Facility
|
OP
|
$23.68
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
10391082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.84 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: Aetna of IA Commercial |
$21.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.31
|
| Rate for Payer: Aetna of IA Medicare |
$13.50
|
| Rate for Payer: Amerigroup Medicaid |
$11.95
|
| Rate for Payer: Amerigroup Medicare |
$11.96
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.76
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.84
|
| Rate for Payer: Medical Associates Commercial |
$17.76
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.84
|
| Rate for Payer: Midlands Choice Commercial |
$16.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.02
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.01
|
| Rate for Payer: Oscar Health of IA Commercial |
$17.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.76
|
| Rate for Payer: United Healthcare Commercial |
$21.31
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.97
|
|
|
furosemide 10 mg/mL Inj Sol 2 mL SDV [VDMC]
|
Facility
|
IP
|
$23.68
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
10391082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.58 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: Aetna of IA Commercial |
$21.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.31
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.76
|
| Rate for Payer: Medical Associates Commercial |
$17.76
|
| Rate for Payer: Midlands Choice Commercial |
$16.58
|
| Rate for Payer: United Healthcare Commercial |
$21.31
|
|
|
furosemide 10 mg/mL Inj Sol 4mL [VDMC]
|
Facility
|
IP
|
$23.88
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
10391216
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.72 |
| Max. Negotiated Rate |
$21.49 |
| Rate for Payer: Aetna of IA Commercial |
$21.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.49
|
| Rate for Payer: Cash Price |
$19.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.91
|
| Rate for Payer: Medical Associates Commercial |
$17.91
|
| Rate for Payer: Midlands Choice Commercial |
$16.72
|
| Rate for Payer: United Healthcare Commercial |
$21.49
|
|
|
furosemide 10 mg/mL Inj Sol 4mL [VDMC]
|
Facility
|
OP
|
$23.88
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
10391216
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$21.49 |
| Rate for Payer: Aetna of IA Commercial |
$21.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.49
|
| Rate for Payer: Aetna of IA Medicare |
$13.61
|
| Rate for Payer: Amerigroup Medicaid |
$12.05
|
| Rate for Payer: Amerigroup Medicare |
$12.06
|
| Rate for Payer: Cash Price |
$19.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.91
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.94
|
| Rate for Payer: Medical Associates Commercial |
$17.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.94
|
| Rate for Payer: Midlands Choice Commercial |
$16.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.12
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.11
|
| Rate for Payer: Oscar Health of IA Commercial |
$17.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.91
|
| Rate for Payer: United Healthcare Commercial |
$21.49
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.09
|
|
|
furosemide 10 mg/mL Oral Liq 60ml [VDMC]
|
Facility
|
IP
|
$28.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.94 |
| Max. Negotiated Rate |
$25.63 |
| Rate for Payer: Aetna of IA Commercial |
$25.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.63
|
| Rate for Payer: Cash Price |
$22.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.36
|
| Rate for Payer: Medical Associates Commercial |
$21.36
|
| Rate for Payer: Midlands Choice Commercial |
$19.94
|
| Rate for Payer: United Healthcare Commercial |
$25.63
|
|
|
furosemide 10 mg/mL Oral Liq 60ml [VDMC]
|
Facility
|
OP
|
$28.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.23 |
| Max. Negotiated Rate |
$25.63 |
| Rate for Payer: Aetna of IA Commercial |
$25.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.63
|
| Rate for Payer: Aetna of IA Medicare |
$16.23
|
| Rate for Payer: Amerigroup Medicaid |
$14.37
|
| Rate for Payer: Amerigroup Medicare |
$14.38
|
| Rate for Payer: Cash Price |
$22.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.23
|
| Rate for Payer: Medical Associates Commercial |
$21.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.24
|
| Rate for Payer: Midlands Choice Commercial |
$19.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.45
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$14.45
|
| Rate for Payer: Oscar Health of IA Commercial |
$21.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.36
|
| Rate for Payer: United Healthcare Commercial |
$25.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.80
|
|
|
furosemide 20 mg Tab [VDMC]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| 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 |
$1.05
|
| 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 |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
|
|
furosemide 20 mg Tab [VDMC]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| 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 |
$0.75
|
| Rate for Payer: Amerigroup Medicaid |
$0.66
|
| Rate for Payer: Amerigroup Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.05
|
| 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 |
$0.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.66
|
| Rate for Payer: Midlands Choice Commercial |
$0.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.66
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
furosemide 40 mg Tab [VDMC]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of IA Commercial |
$1.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.20
|
| Rate for Payer: Aetna of IA Medicare |
$0.76
|
| Rate for Payer: Amerigroup Medicaid |
$0.67
|
| Rate for Payer: Amerigroup Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| 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 |
$0.66
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.67
|
| Rate for Payer: Midlands Choice Commercial |
$0.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.67
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.67
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.78
|
|
|
furosemide 40 mg Tab [VDMC]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of IA Commercial |
$1.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.20
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Midlands Choice Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
G0105 Medicare High risk normal screening colonoscopy
|
Professional
|
Both
|
$1,046.00
|
|
|
Service Code
|
CPT G0105
|
| Hospital Charge Code |
8799222
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$165.95 |
| Max. Negotiated Rate |
$315.30 |
| Rate for Payer: Aetna of IA Medicare |
$165.95
|
| Rate for Payer: Amerigroup Medicaid |
$171.59
|
| Rate for Payer: Cash Price |
$836.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$165.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$169.27
|
| Rate for Payer: Medical Associates Commercial |
$315.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$165.95
|
| Rate for Payer: Midlands Choice Commercial |
$275.51
|
| Rate for Payer: Oscar Health of IA Commercial |
$287.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$248.92
|
|
|
G0121 COLONOSCOPY SCREENING NON RISK
|
Professional
|
Both
|
$1,049.00
|
|
|
Service Code
|
CPT G0121
|
| Hospital Charge Code |
7808122
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$166.10 |
| Max. Negotiated Rate |
$315.59 |
| Rate for Payer: Aetna of IA Medicare |
$166.10
|
| Rate for Payer: Amerigroup Medicaid |
$171.75
|
| Rate for Payer: Cash Price |
$839.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$166.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$169.42
|
| Rate for Payer: Medical Associates Commercial |
$315.59
|
| Rate for Payer: Medical Associates Managed Medicare |
$166.10
|
| Rate for Payer: Midlands Choice Commercial |
$276.02
|
| Rate for Payer: Oscar Health of IA Commercial |
$287.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$249.15
|
|
|
gabapentin 100 mg Cap [VDMC]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391482
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| 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 |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
|
|
gabapentin 100 mg Cap [VDMC]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391482
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| 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 |
$0.75
|
| Rate for Payer: Amerigroup Medicaid |
$0.66
|
| Rate for Payer: Amerigroup Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.66
|
| Rate for Payer: Midlands Choice Commercial |
$0.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.66
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
gabapentin 250 mg/5 mL Solution[VDMC]
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23101177
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$3.34 |
| Rate for Payer: Aetna of IA Commercial |
$3.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.34
|
| Rate for Payer: Aetna of IA Medicare |
$2.11
|
| Rate for Payer: Amerigroup Medicaid |
$1.87
|
| Rate for Payer: Amerigroup Medicare |
$1.87
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.85
|
| Rate for Payer: Medical Associates Commercial |
$2.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.86
|
| Rate for Payer: Midlands Choice Commercial |
$2.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.88
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$2.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.78
|
| Rate for Payer: United Healthcare Commercial |
$3.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.19
|
|
|
gabapentin 250 mg/5 mL Solution[VDMC]
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23101177
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.34 |
| Rate for Payer: Aetna of IA Commercial |
$3.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.34
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.78
|
| Rate for Payer: Medical Associates Commercial |
$2.78
|
| Rate for Payer: Midlands Choice Commercial |
$2.60
|
| Rate for Payer: United Healthcare Commercial |
$3.34
|
|
|
gabapentin 300 mg Cap [VDMC]
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391549
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of IA Commercial |
$1.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.22
|
| Rate for Payer: Aetna of IA Medicare |
$0.78
|
| Rate for Payer: Amerigroup Medicaid |
$0.69
|
| Rate for Payer: Amerigroup Medicare |
$0.69
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.68
|
| Rate for Payer: Medical Associates Commercial |
$1.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.68
|
| Rate for Payer: Midlands Choice Commercial |
$0.95
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.69
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.69
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.22
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.80
|
|
|
gabapentin 300 mg Cap [VDMC]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391549
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of IA Commercial |
$1.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.22
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.02
|
| Rate for Payer: Medical Associates Commercial |
$1.02
|
| Rate for Payer: Midlands Choice Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.22
|
|
|
GAIT THERAPEUTIC TRAINING PER 15 MIN
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 97116 GP
|
| Hospital Charge Code |
1374013
|
|
Hospital Revenue Code
|
420
|
| 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
|
|
|
GAIT THERAPEUTIC TRAINING PER 15 MIN
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 97116 GP
|
| Hospital Charge Code |
1374013
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$56.98 |
| 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 |
$57.54
|
| Rate for Payer: Amerigroup Medicare |
$57.57
|
| 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 |
$57.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.98
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.00
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.86
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$57.82
|
| Rate for Payer: Oscar Health of IA Commercial |
$85.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
|
|
ganciclovir 50 mg/mL 10ml SDV [VDMC]
|
Facility
|
IP
|
$188.48
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
17976474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$131.94 |
| Max. Negotiated Rate |
$169.63 |
| Rate for Payer: Aetna of IA Commercial |
$169.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$169.63
|
| Rate for Payer: Cash Price |
$150.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$141.36
|
| Rate for Payer: Medical Associates Commercial |
$141.36
|
| Rate for Payer: Midlands Choice Commercial |
$131.94
|
| Rate for Payer: United Healthcare Commercial |
$169.63
|
|
|
ganciclovir 50 mg/mL 10ml SDV [VDMC]
|
Facility
|
OP
|
$188.48
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
17976474
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$94.20 |
| Max. Negotiated Rate |
$169.63 |
| Rate for Payer: Aetna of IA Commercial |
$169.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$169.63
|
| Rate for Payer: Aetna of IA Medicare |
$107.43
|
| Rate for Payer: Amerigroup Medicaid |
$95.13
|
| Rate for Payer: Amerigroup Medicare |
$95.18
|
| Rate for Payer: Cash Price |
$150.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$141.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$94.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$94.20
|
| Rate for Payer: Medical Associates Commercial |
$141.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$94.24
|
| Rate for Payer: Midlands Choice Commercial |
$131.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$95.65
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$95.60
|
| Rate for Payer: Oscar Health of IA Commercial |
$141.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$141.36
|
| Rate for Payer: United Healthcare Commercial |
$169.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$111.20
|
|
|
Gastrointestinal Hemorrhage With CC
|
Facility
|
IP
|
$9,102.27
|
|
|
Service Code
|
MS-DRG 378
|
| Hospital Charge Code |
219
|
| Min. Negotiated Rate |
$8,970.35 |
| Max. Negotiated Rate |
$9,102.27 |
| Rate for Payer: Amerigroup Medicaid |
$9,058.29
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,970.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9,102.27
|
|
