|
GENERAL ANESTHESIA II
|
Facility
|
IP
|
$795.00
|
|
| Hospital Charge Code |
8059075
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$556.50 |
| Max. Negotiated Rate |
$715.50 |
| Rate for Payer: Aetna of IA Commercial |
$715.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$715.50
|
| Rate for Payer: Cash Price |
$636.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$596.25
|
| Rate for Payer: Medical Associates Commercial |
$596.25
|
| Rate for Payer: Midlands Choice Commercial |
$556.50
|
| Rate for Payer: United Healthcare Commercial |
$715.50
|
|
|
GENERAL ANESTHESIA II
|
Facility
|
OP
|
$795.00
|
|
| Hospital Charge Code |
8059075
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$397.34 |
| Max. Negotiated Rate |
$715.50 |
| Rate for Payer: Aetna of IA Commercial |
$715.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$715.50
|
| Rate for Payer: Aetna of IA Medicare |
$453.15
|
| Rate for Payer: Amerigroup Medicaid |
$401.24
|
| Rate for Payer: Amerigroup Medicare |
$401.48
|
| Rate for Payer: Cash Price |
$636.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$596.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$397.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$397.34
|
| Rate for Payer: Medical Associates Commercial |
$596.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$397.50
|
| Rate for Payer: Midlands Choice Commercial |
$556.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$403.46
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$403.22
|
| Rate for Payer: Oscar Health of IA Commercial |
$596.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$596.25
|
| Rate for Payer: United Healthcare Commercial |
$715.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$469.05
|
|
|
GENERAL ANESTHESIA III
|
Facility
|
IP
|
$888.00
|
|
| Hospital Charge Code |
8059591
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$621.60 |
| Max. Negotiated Rate |
$799.20 |
| Rate for Payer: Aetna of IA Commercial |
$799.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$799.20
|
| Rate for Payer: Cash Price |
$710.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$666.00
|
| Rate for Payer: Medical Associates Commercial |
$666.00
|
| Rate for Payer: Midlands Choice Commercial |
$621.60
|
| Rate for Payer: United Healthcare Commercial |
$799.20
|
|
|
GENERAL ANESTHESIA III
|
Facility
|
OP
|
$888.00
|
|
| Hospital Charge Code |
8059591
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$443.82 |
| Max. Negotiated Rate |
$799.20 |
| Rate for Payer: Aetna of IA Commercial |
$799.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$799.20
|
| Rate for Payer: Aetna of IA Medicare |
$506.16
|
| Rate for Payer: Amerigroup Medicaid |
$448.17
|
| Rate for Payer: Amerigroup Medicare |
$448.44
|
| Rate for Payer: Cash Price |
$710.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$666.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$444.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$443.82
|
| Rate for Payer: Medical Associates Commercial |
$666.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$444.00
|
| Rate for Payer: Midlands Choice Commercial |
$621.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$450.66
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$450.39
|
| Rate for Payer: Oscar Health of IA Commercial |
$666.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$666.00
|
| Rate for Payer: United Healthcare Commercial |
$799.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$523.92
|
|
|
GENERAL ANESTHESIA IV
|
Facility
|
OP
|
$712.00
|
|
| Hospital Charge Code |
8059076
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$355.86 |
| Max. Negotiated Rate |
$640.80 |
| Rate for Payer: Aetna of IA Commercial |
$640.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$640.80
|
| Rate for Payer: Aetna of IA Medicare |
$405.84
|
| Rate for Payer: Amerigroup Medicaid |
$359.35
|
| Rate for Payer: Amerigroup Medicare |
$359.56
|
| Rate for Payer: Cash Price |
$569.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$534.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$356.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$355.86
|
| Rate for Payer: Medical Associates Commercial |
$534.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$356.00
|
| Rate for Payer: Midlands Choice Commercial |
$498.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$361.34
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$361.13
|
| Rate for Payer: Oscar Health of IA Commercial |
$534.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$534.00
|
| Rate for Payer: United Healthcare Commercial |
$640.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$420.08
|
|
|
GENERAL ANESTHESIA IV
|
Facility
|
IP
|
$712.00
|
|
| Hospital Charge Code |
8059076
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$498.40 |
| Max. Negotiated Rate |
$640.80 |
| Rate for Payer: Aetna of IA Commercial |
$640.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$640.80
|
| Rate for Payer: Cash Price |
$569.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$534.00
|
| Rate for Payer: Medical Associates Commercial |
$534.00
|
| Rate for Payer: Midlands Choice Commercial |
$498.40
|
| Rate for Payer: United Healthcare Commercial |
$640.80
|
|
|
GENERAL HEALTH PANEL
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
7805074
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$240.80 |
| Max. Negotiated Rate |
$309.60 |
| Rate for Payer: Aetna of IA Commercial |
$309.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$309.60
|
| Rate for Payer: Cash Price |
$275.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$258.00
|
| Rate for Payer: Medical Associates Commercial |
$258.00
|
| Rate for Payer: Midlands Choice Commercial |
$240.80
|
| Rate for Payer: United Healthcare Commercial |
$309.60
|
|
|
GENERAL HEALTH PANEL
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
7805074
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$309.60 |
| Rate for Payer: Aetna of IA Commercial |
$309.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$309.60
|
| Rate for Payer: Aetna of IA Medicare |
$196.08
|
| Rate for Payer: Amerigroup Medicaid |
$173.62
|
| Rate for Payer: Amerigroup Medicare |
$173.72
|
| Rate for Payer: Cash Price |
$275.20
|
| Rate for Payer: Cash Price |
$275.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$258.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$172.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$171.93
|
| Rate for Payer: Medical Associates Commercial |
$258.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$172.00
|
| Rate for Payer: Midlands Choice Commercial |
$240.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$174.58
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$174.48
|
| Rate for Payer: Oscar Health of IA Commercial |
$258.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$258.00
|
| Rate for Payer: United Healthcare Commercial |
$309.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$202.96
|
| Rate for Payer: Wellmark IA HMO |
$52.08
|
| Rate for Payer: Wellmark IA PPO |
$57.29
|
|
|
gentamicin 0.1% cream 15gm Tube [VDMC]
|
Facility
|
IP
|
$96.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$67.26 |
| Max. Negotiated Rate |
$86.47 |
| Rate for Payer: Aetna of IA Commercial |
$86.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.47
|
| Rate for Payer: Cash Price |
$76.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.06
|
| Rate for Payer: Medical Associates Commercial |
$72.06
|
| Rate for Payer: Midlands Choice Commercial |
$67.26
|
| Rate for Payer: United Healthcare Commercial |
$86.47
|
|
|
gentamicin 0.1% cream 15gm Tube [VDMC]
|
Facility
|
OP
|
$96.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$86.47 |
| Rate for Payer: Aetna of IA Commercial |
$86.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$86.47
|
| Rate for Payer: Aetna of IA Medicare |
$54.77
|
| Rate for Payer: Amerigroup Medicaid |
$48.49
|
| Rate for Payer: Amerigroup Medicare |
$48.52
|
| Rate for Payer: Cash Price |
$76.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$48.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$48.02
|
| Rate for Payer: Medical Associates Commercial |
$72.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$48.04
|
| Rate for Payer: Midlands Choice Commercial |
$67.26
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$48.76
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$48.73
|
| Rate for Payer: Oscar Health of IA Commercial |
$72.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$72.06
|
| Rate for Payer: United Healthcare Commercial |
$86.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$56.69
|
|
|
gentamicin 10 mg/mL 2ml [VDMC]
|
Facility
|
IP
|
$26.88
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391689
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.82 |
| Max. Negotiated Rate |
$24.19 |
| Rate for Payer: Aetna of IA Commercial |
$24.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.19
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.16
|
| Rate for Payer: Medical Associates Commercial |
$20.16
|
| Rate for Payer: Midlands Choice Commercial |
$18.82
|
| Rate for Payer: United Healthcare Commercial |
$24.19
|
|
|
gentamicin 10 mg/mL 2ml [VDMC]
|
Facility
|
OP
|
$26.88
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391689
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$24.19 |
| Rate for Payer: Aetna of IA Commercial |
$24.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.19
|
| Rate for Payer: Aetna of IA Medicare |
$15.32
|
| Rate for Payer: Amerigroup Medicaid |
$13.57
|
| Rate for Payer: Amerigroup Medicare |
$13.57
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.43
|
| Rate for Payer: Medical Associates Commercial |
$20.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.44
|
| Rate for Payer: Midlands Choice Commercial |
$18.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.64
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$13.63
|
| Rate for Payer: Oscar Health of IA Commercial |
$20.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.16
|
| Rate for Payer: United Healthcare Commercial |
$24.19
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.86
|
|
|
gentamicin 40 mg/mL 20ml Inj Sol [VDMC]
|
Facility
|
OP
|
$110.91
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391760
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.43 |
| Max. Negotiated Rate |
$99.82 |
| Rate for Payer: Aetna of IA Commercial |
$99.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.82
|
| Rate for Payer: Aetna of IA Medicare |
$63.22
|
| Rate for Payer: Amerigroup Medicaid |
$55.98
|
| Rate for Payer: Amerigroup Medicare |
$56.01
|
| Rate for Payer: Cash Price |
$88.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.43
|
| Rate for Payer: Medical Associates Commercial |
$83.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.46
|
| Rate for Payer: Midlands Choice Commercial |
$77.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.29
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$56.25
|
| Rate for Payer: Oscar Health of IA Commercial |
$83.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.18
|
| Rate for Payer: United Healthcare Commercial |
$99.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.44
|
|
|
gentamicin 40 mg/mL 20ml Inj Sol [VDMC]
|
Facility
|
IP
|
$110.91
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391760
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$77.64 |
| Max. Negotiated Rate |
$99.82 |
| Rate for Payer: Aetna of IA Commercial |
$99.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.82
|
| Rate for Payer: Cash Price |
$88.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.18
|
| Rate for Payer: Medical Associates Commercial |
$83.18
|
| Rate for Payer: Midlands Choice Commercial |
$77.64
|
| Rate for Payer: United Healthcare Commercial |
$99.82
|
|
|
gentamicin 80 mg/100 mL-NS IV Sol [VDMC]
|
Facility
|
OP
|
$57.33
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391831
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.65 |
| Max. Negotiated Rate |
$51.60 |
| Rate for Payer: Aetna of IA Commercial |
$51.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.60
|
| Rate for Payer: Aetna of IA Medicare |
$32.68
|
| Rate for Payer: Amerigroup Medicaid |
$28.93
|
| Rate for Payer: Amerigroup Medicare |
$28.95
|
| Rate for Payer: Cash Price |
$45.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.65
|
| Rate for Payer: Medical Associates Commercial |
$43.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.66
|
| Rate for Payer: Midlands Choice Commercial |
$40.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.09
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$29.08
|
| Rate for Payer: Oscar Health of IA Commercial |
$43.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$43.00
|
| Rate for Payer: United Healthcare Commercial |
$51.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.82
|
|
|
gentamicin 80 mg/100 mL-NS IV Sol [VDMC]
|
Facility
|
IP
|
$57.33
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
10391831
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.13 |
| Max. Negotiated Rate |
$51.60 |
| Rate for Payer: Aetna of IA Commercial |
$51.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.60
|
| Rate for Payer: Cash Price |
$45.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.00
|
| Rate for Payer: Medical Associates Commercial |
$43.00
|
| Rate for Payer: Midlands Choice Commercial |
$40.13
|
| Rate for Payer: United Healthcare Commercial |
$51.60
|
|
|
gentamicin Ophth 0.3% Oint 3.5gm Tube [VDMC]
|
Facility
|
IP
|
$67.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.52 |
| Max. Negotiated Rate |
$61.09 |
| Rate for Payer: Aetna of IA Commercial |
$61.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$61.09
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.91
|
| Rate for Payer: Medical Associates Commercial |
$50.91
|
| Rate for Payer: Midlands Choice Commercial |
$47.52
|
| Rate for Payer: United Healthcare Commercial |
$61.09
|
|
|
gentamicin Ophth 0.3% Oint 3.5gm Tube [VDMC]
|
Facility
|
OP
|
$67.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.93 |
| Max. Negotiated Rate |
$61.09 |
| Rate for Payer: Aetna of IA Commercial |
$61.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$61.09
|
| Rate for Payer: Aetna of IA Medicare |
$38.69
|
| Rate for Payer: Amerigroup Medicaid |
$34.26
|
| Rate for Payer: Amerigroup Medicare |
$34.28
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.91
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$33.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.93
|
| Rate for Payer: Medical Associates Commercial |
$50.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.94
|
| Rate for Payer: Midlands Choice Commercial |
$47.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$34.45
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$34.43
|
| Rate for Payer: Oscar Health of IA Commercial |
$50.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$50.91
|
| Rate for Payer: United Healthcare Commercial |
$61.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$40.05
|
|
|
gentamicin Ophth 0.3% Sol 5ml Bottle [VDMC]
|
Facility
|
OP
|
$27.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434650
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$24.73 |
| Rate for Payer: Aetna of IA Commercial |
$24.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.73
|
| Rate for Payer: Aetna of IA Medicare |
$15.66
|
| Rate for Payer: Amerigroup Medicaid |
$13.87
|
| Rate for Payer: Amerigroup Medicare |
$13.88
|
| Rate for Payer: Cash Price |
$21.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.61
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.73
|
| Rate for Payer: Medical Associates Commercial |
$20.61
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.74
|
| Rate for Payer: Midlands Choice Commercial |
$19.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.95
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$13.94
|
| Rate for Payer: Oscar Health of IA Commercial |
$20.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.61
|
| Rate for Payer: United Healthcare Commercial |
$24.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.21
|
|
|
gentamicin Ophth 0.3% Sol 5ml Bottle [VDMC]
|
Facility
|
IP
|
$27.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434650
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.24 |
| Max. Negotiated Rate |
$24.73 |
| Rate for Payer: Aetna of IA Commercial |
$24.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.73
|
| Rate for Payer: Cash Price |
$21.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.61
|
| Rate for Payer: Medical Associates Commercial |
$20.61
|
| Rate for Payer: Midlands Choice Commercial |
$19.24
|
| Rate for Payer: United Healthcare Commercial |
$24.73
|
|
|
GENTAMYCIN LEVEL
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633736
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of IA Commercial |
$100.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.80
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.00
|
| Rate for Payer: Medical Associates Commercial |
$84.00
|
| Rate for Payer: Midlands Choice Commercial |
$78.40
|
| Rate for Payer: United Healthcare Commercial |
$100.80
|
|
|
GENTAMYCIN LEVEL
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633735
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of IA Commercial |
$100.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.80
|
| Rate for Payer: Aetna of IA Medicare |
$63.84
|
| Rate for Payer: Amerigroup Medicaid |
$56.53
|
| Rate for Payer: Amerigroup Medicare |
$56.56
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$56.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.98
|
| Rate for Payer: Medical Associates Commercial |
$84.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$56.00
|
| Rate for Payer: Midlands Choice Commercial |
$78.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.84
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$56.81
|
| Rate for Payer: Oscar Health of IA Commercial |
$84.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$84.00
|
| Rate for Payer: United Healthcare Commercial |
$100.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$66.08
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
GENTAMYCIN LEVEL
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633735
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of IA Commercial |
$100.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.80
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.00
|
| Rate for Payer: Medical Associates Commercial |
$84.00
|
| Rate for Payer: Midlands Choice Commercial |
$78.40
|
| Rate for Payer: United Healthcare Commercial |
$100.80
|
|
|
GENTAMYCIN LEVEL
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633736
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of IA Commercial |
$100.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.80
|
| Rate for Payer: Aetna of IA Medicare |
$63.84
|
| Rate for Payer: Amerigroup Medicaid |
$56.53
|
| Rate for Payer: Amerigroup Medicare |
$56.56
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$84.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$56.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.98
|
| Rate for Payer: Medical Associates Commercial |
$84.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$56.00
|
| Rate for Payer: Midlands Choice Commercial |
$78.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.84
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$56.81
|
| Rate for Payer: Oscar Health of IA Commercial |
$84.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$84.00
|
| Rate for Payer: United Healthcare Commercial |
$100.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$66.08
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
gentian violet 1% topical solution [VDMC]
|
Facility
|
OP
|
$19.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11340289
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna of IA Commercial |
$17.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$17.32
|
| Rate for Payer: Aetna of IA Medicare |
$10.97
|
| Rate for Payer: Amerigroup Medicaid |
$9.71
|
| Rate for Payer: Amerigroup Medicare |
$9.72
|
| Rate for Payer: Cash Price |
$15.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.62
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.62
|
| Rate for Payer: Medical Associates Commercial |
$14.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.62
|
| Rate for Payer: Midlands Choice Commercial |
$13.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.76
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$9.76
|
| Rate for Payer: Oscar Health of IA Commercial |
$14.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.43
|
| Rate for Payer: United Healthcare Commercial |
$17.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.35
|
|
