|
iron dextran 50 mg/mL 2 ml Inj Sol [VDMC]
|
Facility
|
IP
|
$87.43
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
29045726
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$78.69 |
| Rate for Payer: Aetna of IA Commercial |
$78.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$78.69
|
| Rate for Payer: Cash Price |
$69.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.57
|
| Rate for Payer: Medical Associates Commercial |
$65.57
|
| Rate for Payer: Midlands Choice Commercial |
$61.20
|
| Rate for Payer: United Healthcare Commercial |
$78.69
|
|
|
iron dextran 50 mg/mL 2 ml Inj Sol [VDMC]
|
Facility
|
OP
|
$87.43
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
29045726
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.34 |
| Max. Negotiated Rate |
$78.69 |
| Rate for Payer: Aetna of IA Commercial |
$78.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$78.69
|
| Rate for Payer: Aetna of IA Medicare |
$49.84
|
| Rate for Payer: Amerigroup Medicaid |
$50.43
|
| Rate for Payer: Amerigroup Medicare |
$39.74
|
| Rate for Payer: Cash Price |
$69.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.57
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$39.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$49.94
|
| Rate for Payer: Medical Associates Commercial |
$65.57
|
| Rate for Payer: Medical Associates Managed Medicare |
$39.34
|
| Rate for Payer: Midlands Choice Commercial |
$61.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$50.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.25
|
| Rate for Payer: United Healthcare Commercial |
$78.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$51.58
|
|
|
IRON IRON BINDING
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
4018195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$30.49 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of IA Commercial |
$64.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.80
|
| Rate for Payer: Aetna of IA Medicare |
$41.04
|
| Rate for Payer: Amerigroup Medicaid |
$41.53
|
| Rate for Payer: Amerigroup Medicare |
$32.72
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$41.13
|
| Rate for Payer: Medical Associates Commercial |
$54.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.40
|
| Rate for Payer: Midlands Choice Commercial |
$50.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$37.26
|
| Rate for Payer: United Healthcare Commercial |
$64.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$42.48
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
IRON IRON BINDING
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
4018195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of IA Commercial |
$64.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.80
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.00
|
| Rate for Payer: Medical Associates Commercial |
$54.00
|
| Rate for Payer: Midlands Choice Commercial |
$50.40
|
| Rate for Payer: United Healthcare Commercial |
$64.80
|
|
|
iron sucrose 20 mg/mL IV 5 ml SDV Sol [VDMC]
|
Facility
|
IP
|
$140.90
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
10397566
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$98.63 |
| Max. Negotiated Rate |
$126.81 |
| Rate for Payer: Aetna of IA Commercial |
$126.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.81
|
| Rate for Payer: Cash Price |
$112.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.68
|
| Rate for Payer: Medical Associates Commercial |
$105.68
|
| Rate for Payer: Midlands Choice Commercial |
$98.63
|
| Rate for Payer: United Healthcare Commercial |
$126.81
|
|
|
iron sucrose 20 mg/mL IV 5 ml SDV Sol [VDMC]
|
Facility
|
OP
|
$140.90
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
10397566
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.40 |
| Max. Negotiated Rate |
$126.81 |
| Rate for Payer: Aetna of IA Commercial |
$126.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.81
|
| Rate for Payer: Aetna of IA Medicare |
$80.31
|
| Rate for Payer: Amerigroup Medicaid |
$81.27
|
| Rate for Payer: Amerigroup Medicare |
$64.04
|
| Rate for Payer: Cash Price |
$112.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$63.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$80.48
|
| Rate for Payer: Medical Associates Commercial |
$105.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$63.40
|
| Rate for Payer: Midlands Choice Commercial |
$98.63
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$81.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$72.92
|
| Rate for Payer: United Healthcare Commercial |
$126.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$83.13
|
|
|
Irrigation sodium chloride 0.9% Sol 1000 mL Bottle [VDMC]
|
Facility
|
OP
|
$67.16
|
|
|
Service Code
|
NDC 00338-0048-04
|
| Hospital Charge Code |
10438212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.22 |
| Max. Negotiated Rate |
$60.44 |
| Rate for Payer: Aetna of IA Commercial |
$60.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.44
|
| Rate for Payer: Aetna of IA Medicare |
$38.28
|
| Rate for Payer: Amerigroup Medicaid |
$38.74
|
| Rate for Payer: Amerigroup Medicare |
$30.52
|
| Rate for Payer: Cash Price |
$53.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.37
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.36
|
| Rate for Payer: Medical Associates Commercial |
$50.37
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.22
|
| Rate for Payer: Midlands Choice Commercial |
$47.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.76
|
| Rate for Payer: United Healthcare Commercial |
$60.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.62
|
|
|
Irrigation sodium chloride 0.9% Sol 1000 mL Bottle [VDMC]
|
Facility
|
IP
|
$67.16
|
|
|
Service Code
|
NDC 00338-0048-04
|
| Hospital Charge Code |
10438212
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.01 |
| Max. Negotiated Rate |
$60.44 |
| Rate for Payer: Aetna of IA Commercial |
$60.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.44
|
| Rate for Payer: Cash Price |
$53.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.37
|
| Rate for Payer: Medical Associates Commercial |
$50.37
|
| Rate for Payer: Midlands Choice Commercial |
$47.01
|
| Rate for Payer: United Healthcare Commercial |
$60.44
|
|
|
Irrigation sodium chloride 0.9% Sol 250 mL Bottle [VDMC]
|
Facility
|
OP
|
$76.72
|
|
|
Service Code
|
NDC 00338-0048-02
|
| Hospital Charge Code |
10438279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.52 |
| Max. Negotiated Rate |
$69.05 |
| Rate for Payer: Aetna of IA Commercial |
$69.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.05
|
| Rate for Payer: Aetna of IA Medicare |
$43.73
|
| Rate for Payer: Amerigroup Medicaid |
$44.25
|
| Rate for Payer: Amerigroup Medicare |
$34.87
|
| Rate for Payer: Cash Price |
$61.38
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$34.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$43.82
|
| Rate for Payer: Medical Associates Commercial |
$57.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$34.52
|
| Rate for Payer: Midlands Choice Commercial |
$53.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$44.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.70
|
| Rate for Payer: United Healthcare Commercial |
$69.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$45.26
|
|
|
Irrigation sodium chloride 0.9% Sol 250 mL Bottle [VDMC]
|
Facility
|
IP
|
$76.72
|
|
|
Service Code
|
NDC 00338-0048-02
|
| Hospital Charge Code |
10438279
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.70 |
| Max. Negotiated Rate |
$69.05 |
| Rate for Payer: Aetna of IA Commercial |
$69.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.05
|
| Rate for Payer: Cash Price |
$61.38
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.54
|
| Rate for Payer: Medical Associates Commercial |
$57.54
|
| Rate for Payer: Midlands Choice Commercial |
$53.70
|
| Rate for Payer: United Healthcare Commercial |
$69.05
|
|
|
Irrigation sodium chloride 0.9% Sol 3000 mL [VDMC]
|
Facility
|
OP
|
$77.88
|
|
|
Service Code
|
NDC 00990-7972-08
|
| Hospital Charge Code |
10438346
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.05 |
| Max. Negotiated Rate |
$70.09 |
| Rate for Payer: Aetna of IA Commercial |
$70.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.09
|
| Rate for Payer: Aetna of IA Medicare |
$44.39
|
| Rate for Payer: Amerigroup Medicaid |
$44.92
|
| Rate for Payer: Amerigroup Medicare |
$35.40
|
| Rate for Payer: Cash Price |
$62.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.41
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$35.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$44.49
|
| Rate for Payer: Medical Associates Commercial |
$58.41
|
| Rate for Payer: Medical Associates Managed Medicare |
$35.05
|
| Rate for Payer: Midlands Choice Commercial |
$54.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$45.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.30
|
| Rate for Payer: United Healthcare Commercial |
$70.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$45.95
|
|
|
Irrigation sodium chloride 0.9% Sol 3000 mL [VDMC]
|
Facility
|
IP
|
$77.88
|
|
|
Service Code
|
NDC 00990-7972-08
|
| Hospital Charge Code |
10438346
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.52 |
| Max. Negotiated Rate |
$70.09 |
| Rate for Payer: Aetna of IA Commercial |
$70.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.09
|
| Rate for Payer: Cash Price |
$62.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.41
|
| Rate for Payer: Medical Associates Commercial |
$58.41
|
| Rate for Payer: Midlands Choice Commercial |
$54.52
|
| Rate for Payer: United Healthcare Commercial |
$70.09
|
|
|
Irrigation sodium chloride 0.9% Sol 500 mL Bottle [VDMC]
|
Facility
|
OP
|
$71.10
|
|
|
Service Code
|
NDC 00338-0048-03
|
| Hospital Charge Code |
10438413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$63.99 |
| Rate for Payer: Aetna of IA Commercial |
$63.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.99
|
| Rate for Payer: Aetna of IA Medicare |
$40.53
|
| Rate for Payer: Amerigroup Medicaid |
$41.01
|
| Rate for Payer: Amerigroup Medicare |
$32.31
|
| Rate for Payer: Cash Price |
$56.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40.61
|
| Rate for Payer: Medical Associates Commercial |
$53.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.00
|
| Rate for Payer: Midlands Choice Commercial |
$49.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.21
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.79
|
| Rate for Payer: United Healthcare Commercial |
$63.99
|
| Rate for Payer: United Healthcare Managed Medicare |
$41.95
|
|
|
Irrigation sodium chloride 0.9% Sol 500 mL Bottle [VDMC]
|
Facility
|
IP
|
$71.10
|
|
|
Service Code
|
NDC 00338-0048-03
|
| Hospital Charge Code |
10438413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.77 |
| Max. Negotiated Rate |
$63.99 |
| Rate for Payer: Aetna of IA Commercial |
$63.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.99
|
| Rate for Payer: Cash Price |
$56.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.32
|
| Rate for Payer: Medical Associates Commercial |
$53.32
|
| Rate for Payer: Midlands Choice Commercial |
$49.77
|
| Rate for Payer: United Healthcare Commercial |
$63.99
|
|
|
IRRIG DRUG DELIVERY DEVICE
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
4866826
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$37.58 |
| Max. Negotiated Rate |
$141.30 |
| Rate for Payer: Aetna of IA Commercial |
$141.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$141.30
|
| Rate for Payer: Aetna of IA Medicare |
$89.49
|
| Rate for Payer: Amerigroup Medicaid |
$90.56
|
| Rate for Payer: Amerigroup Medicare |
$71.36
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$117.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$70.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.68
|
| Rate for Payer: Medical Associates Commercial |
$117.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$70.65
|
| Rate for Payer: Midlands Choice Commercial |
$109.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.25
|
| Rate for Payer: United Healthcare Commercial |
$141.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$92.63
|
| Rate for Payer: Wellmark IA HMO WHPI |
$37.58
|
| Rate for Payer: Wellmark IA PPO |
$41.39
|
|
|
IRRIG DRUG DELIVERY DEVICE
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
4866826
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$109.90 |
| Max. Negotiated Rate |
$141.30 |
| Rate for Payer: Aetna of IA Commercial |
$141.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$141.30
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$117.75
|
| Rate for Payer: Medical Associates Commercial |
$117.75
|
| Rate for Payer: Midlands Choice Commercial |
$109.90
|
| Rate for Payer: United Healthcare Commercial |
$141.30
|
|
|
IRRIG DRUG DELIVERY DEVICE
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
8398094
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$37.58 |
| Max. Negotiated Rate |
$141.30 |
| Rate for Payer: Aetna of IA Commercial |
$141.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$141.30
|
| Rate for Payer: Aetna of IA Medicare |
$89.49
|
| Rate for Payer: Amerigroup Medicaid |
$90.56
|
| Rate for Payer: Amerigroup Medicare |
$71.36
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$117.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$70.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.68
|
| Rate for Payer: Medical Associates Commercial |
$117.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$70.65
|
| Rate for Payer: Midlands Choice Commercial |
$109.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.25
|
| Rate for Payer: United Healthcare Commercial |
$141.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$92.63
|
| Rate for Payer: Wellmark IA HMO WHPI |
$37.58
|
| Rate for Payer: Wellmark IA PPO |
$41.39
|
|
|
IRRIG DRUG DELIVERY DEVICE
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
8398094
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$109.90 |
| Max. Negotiated Rate |
$141.30 |
| Rate for Payer: Aetna of IA Commercial |
$141.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$141.30
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$117.75
|
| Rate for Payer: Medical Associates Commercial |
$117.75
|
| Rate for Payer: Midlands Choice Commercial |
$109.90
|
| Rate for Payer: United Healthcare Commercial |
$141.30
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC
|
Facility
|
IP
|
$22,795.40
|
|
|
Service Code
|
MSDRG 062
|
| Min. Negotiated Rate |
$22,465.03 |
| Max. Negotiated Rate |
$22,795.40 |
| Rate for Payer: Amerigroup Medicaid |
$22,685.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22,465.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22,795.40
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC
|
Facility
|
IP
|
$27,442.31
|
|
|
Service Code
|
MSDRG 061
|
| Min. Negotiated Rate |
$27,044.58 |
| Max. Negotiated Rate |
$27,442.31 |
| Rate for Payer: Amerigroup Medicaid |
$27,309.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27,044.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27,442.31
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC
|
Facility
|
IP
|
$20,242.81
|
|
|
Service Code
|
MSDRG 063
|
| Min. Negotiated Rate |
$19,949.43 |
| Max. Negotiated Rate |
$20,242.81 |
| Rate for Payer: Amerigroup Medicaid |
$20,145.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19,949.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20,242.81
|
|
|
Isolation
|
Facility
|
IP
|
$230.00
|
|
| Hospital Charge Code |
7861839
|
|
Hospital Revenue Code
|
110
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$2,580.60 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Aetna of IA Medicare |
$2,258.00
|
| Rate for Payer: Amerigroup Medicare |
$2,266.44
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,244.00
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,244.00
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,580.60
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,306.00
|
|
|
isoniazid 100 mg Tab [VDMC]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10397637
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of IA Commercial |
$1.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.16
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.74
|
| Rate for Payer: Medical Associates Commercial |
$0.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.67
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.76
|
|
|
isoniazid 100 mg Tab [VDMC]
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10397637
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of IA Commercial |
$1.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.16
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.97
|
| Rate for Payer: Medical Associates Commercial |
$0.97
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
|
|
isosorbide mononitrate 20 mg Tab [VDMC]
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10397848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of IA Commercial |
$1.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.38
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Midlands Choice Commercial |
$1.07
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
|
