|
ketamine 100 mg/mL 10 ml MDV Inj Sol [VDMC]
|
Facility
|
OP
|
$62.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
26412384
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.31 |
| Max. Negotiated Rate |
$56.62 |
| Rate for Payer: Aetna of IA Commercial |
$56.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.62
|
| Rate for Payer: Aetna of IA Medicare |
$35.86
|
| Rate for Payer: Amerigroup Medicaid |
$36.29
|
| Rate for Payer: Amerigroup Medicare |
$28.59
|
| Rate for Payer: Cash Price |
$50.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.93
|
| Rate for Payer: Medical Associates Commercial |
$47.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.31
|
| Rate for Payer: Midlands Choice Commercial |
$44.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.55
|
| Rate for Payer: United Healthcare Commercial |
$56.62
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.12
|
|
|
ketamine 100 mg/mL 5 ml inj Sol [VDMC]
|
Facility
|
OP
|
$65.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
14651303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.59 |
| Max. Negotiated Rate |
$59.18 |
| Rate for Payer: Aetna of IA Commercial |
$59.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.18
|
| Rate for Payer: Aetna of IA Medicare |
$37.48
|
| Rate for Payer: Amerigroup Medicaid |
$37.93
|
| Rate for Payer: Amerigroup Medicare |
$29.89
|
| Rate for Payer: Cash Price |
$52.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.56
|
| Rate for Payer: Medical Associates Commercial |
$49.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.59
|
| Rate for Payer: Midlands Choice Commercial |
$46.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.03
|
| Rate for Payer: United Healthcare Commercial |
$59.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.80
|
|
|
ketamine 100 mg/mL 5 ml inj Sol [VDMC]
|
Facility
|
IP
|
$65.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
14651303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.03 |
| Max. Negotiated Rate |
$59.18 |
| Rate for Payer: Aetna of IA Commercial |
$59.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.18
|
| Rate for Payer: Cash Price |
$52.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.32
|
| Rate for Payer: Medical Associates Commercial |
$49.32
|
| Rate for Payer: Midlands Choice Commercial |
$46.03
|
| Rate for Payer: United Healthcare Commercial |
$59.18
|
|
|
ketamine 10 mg/mL 20 ml MDV Inj Sol [VDMC]
|
Facility
|
OP
|
$111.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
26431860
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.96 |
| Max. Negotiated Rate |
$99.92 |
| Rate for Payer: Aetna of IA Commercial |
$99.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.92
|
| Rate for Payer: Aetna of IA Medicare |
$63.28
|
| Rate for Payer: Amerigroup Medicaid |
$64.04
|
| Rate for Payer: Amerigroup Medicare |
$50.46
|
| Rate for Payer: Cash Price |
$88.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.26
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$63.41
|
| Rate for Payer: Medical Associates Commercial |
$83.26
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.96
|
| Rate for Payer: Midlands Choice Commercial |
$77.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$64.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.45
|
| Rate for Payer: United Healthcare Commercial |
$99.92
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.50
|
|
|
ketamine 10 mg/mL 20 ml MDV Inj Sol [VDMC]
|
Facility
|
IP
|
$111.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
26431860
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$77.71 |
| Max. Negotiated Rate |
$99.92 |
| Rate for Payer: Aetna of IA Commercial |
$99.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.92
|
| Rate for Payer: Cash Price |
$88.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.26
|
| Rate for Payer: Medical Associates Commercial |
$83.26
|
| Rate for Payer: Midlands Choice Commercial |
$77.71
|
| Rate for Payer: United Healthcare Commercial |
$99.92
|
|
|
ketamine 50 mg/mL 10 ml MDV Inj Sol [VDMC]
|
Facility
|
OP
|
$48.12
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10398197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.65 |
| Max. Negotiated Rate |
$43.30 |
| Rate for Payer: Aetna of IA Commercial |
$43.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.30
|
| Rate for Payer: Aetna of IA Medicare |
$27.43
|
| Rate for Payer: Amerigroup Medicaid |
$27.75
|
| Rate for Payer: Amerigroup Medicare |
$21.87
|
| Rate for Payer: Cash Price |
$38.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27.48
|
| Rate for Payer: Medical Associates Commercial |
$36.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.65
|
| Rate for Payer: Midlands Choice Commercial |
$33.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.90
|
| Rate for Payer: United Healthcare Commercial |
$43.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.39
|
|
|
ketamine 50 mg/mL 10 ml MDV Inj Sol [VDMC]
|
Facility
|
IP
|
$48.12
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10398197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.68 |
| Max. Negotiated Rate |
$43.30 |
| Rate for Payer: Aetna of IA Commercial |
$43.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.30
|
| Rate for Payer: Cash Price |
$38.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.09
|
| Rate for Payer: Medical Associates Commercial |
$36.09
|
| Rate for Payer: Midlands Choice Commercial |
$33.68
|
| Rate for Payer: United Healthcare Commercial |
$43.30
|
|
|
ketoconazole 200 mg Tab [VDMC]
|
Facility
|
IP
|
$4.87
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10398264
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna of IA Commercial |
$4.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.38
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.65
|
| Rate for Payer: Medical Associates Commercial |
$3.65
|
| Rate for Payer: Midlands Choice Commercial |
$3.41
|
| Rate for Payer: United Healthcare Commercial |
$4.38
|
|
|
ketoconazole 200 mg Tab [VDMC]
|
Facility
|
OP
|
$4.87
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10398264
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna of IA Commercial |
$4.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.38
|
| Rate for Payer: Aetna of IA Medicare |
$2.77
|
| Rate for Payer: Amerigroup Medicaid |
$2.81
|
| Rate for Payer: Amerigroup Medicare |
$2.21
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.65
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.19
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.78
|
| Rate for Payer: Medical Associates Commercial |
$3.65
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.19
|
| Rate for Payer: Midlands Choice Commercial |
$3.41
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.52
|
| Rate for Payer: United Healthcare Commercial |
$4.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.87
|
|
|
ketoconazole Top 2% Crm 15gm [VDMC]
|
Facility
|
IP
|
$57.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.12 |
| Max. Negotiated Rate |
$51.59 |
| Rate for Payer: Aetna of IA Commercial |
$51.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.59
|
| Rate for Payer: Cash Price |
$45.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.99
|
| Rate for Payer: Medical Associates Commercial |
$42.99
|
| Rate for Payer: Midlands Choice Commercial |
$40.12
|
| Rate for Payer: United Healthcare Commercial |
$51.59
|
|
|
ketoconazole Top 2% Crm 15gm [VDMC]
|
Facility
|
OP
|
$57.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.79 |
| Max. Negotiated Rate |
$51.59 |
| Rate for Payer: Aetna of IA Commercial |
$51.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.59
|
| Rate for Payer: Aetna of IA Medicare |
$32.67
|
| Rate for Payer: Amerigroup Medicaid |
$33.06
|
| Rate for Payer: Amerigroup Medicare |
$26.05
|
| Rate for Payer: Cash Price |
$45.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.99
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$25.79
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.74
|
| Rate for Payer: Medical Associates Commercial |
$42.99
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.79
|
| Rate for Payer: Midlands Choice Commercial |
$40.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$29.66
|
| Rate for Payer: United Healthcare Commercial |
$51.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.82
|
|
|
ketoconazole topical 2% Shampoo 120 ml[VDMC]
|
Facility
|
OP
|
$43.84
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
21026900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.73 |
| Max. Negotiated Rate |
$39.46 |
| Rate for Payer: Aetna of IA Commercial |
$39.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.46
|
| Rate for Payer: Aetna of IA Medicare |
$24.99
|
| Rate for Payer: Amerigroup Medicaid |
$25.29
|
| Rate for Payer: Amerigroup Medicare |
$19.93
|
| Rate for Payer: Cash Price |
$35.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$25.04
|
| Rate for Payer: Medical Associates Commercial |
$32.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.73
|
| Rate for Payer: Midlands Choice Commercial |
$30.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.41
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.69
|
| Rate for Payer: United Healthcare Commercial |
$39.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.87
|
|
|
ketoconazole topical 2% Shampoo 120 ml[VDMC]
|
Facility
|
IP
|
$43.84
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
21026900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.69 |
| Max. Negotiated Rate |
$39.46 |
| Rate for Payer: Aetna of IA Commercial |
$39.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.46
|
| Rate for Payer: Cash Price |
$35.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.88
|
| Rate for Payer: Medical Associates Commercial |
$32.88
|
| Rate for Payer: Midlands Choice Commercial |
$30.69
|
| Rate for Payer: United Healthcare Commercial |
$39.46
|
|
|
KETONES SERUM
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
4022840
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$27.45 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Aetna of IA Medicare |
$34.77
|
| Rate for Payer: Amerigroup Medicaid |
$35.18
|
| Rate for Payer: Amerigroup Medicare |
$27.72
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$34.84
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.45
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.57
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.99
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
KETONES SERUM
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
4022840
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
|
|
ketorolac 10 mg Tab [VDMC]
|
Facility
|
OP
|
$3.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10398333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna of IA Commercial |
$3.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.56
|
| Rate for Payer: Aetna of IA Medicare |
$2.26
|
| Rate for Payer: Amerigroup Medicaid |
$2.28
|
| Rate for Payer: Amerigroup Medicare |
$1.80
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.26
|
| Rate for Payer: Medical Associates Commercial |
$2.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.78
|
| Rate for Payer: Midlands Choice Commercial |
$2.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.29
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.05
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.34
|
|
|
ketorolac 10 mg Tab [VDMC]
|
Facility
|
IP
|
$3.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10398333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna of IA Commercial |
$3.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.56
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.97
|
| Rate for Payer: Medical Associates Commercial |
$2.97
|
| Rate for Payer: Midlands Choice Commercial |
$2.77
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
|
|
ketorolac 15 mg/mL 1ml Inj SDV [VDMC]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$20.05 |
| Rate for Payer: Aetna of IA Commercial |
$20.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.05
|
| Rate for Payer: Cash Price |
$17.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.71
|
| Rate for Payer: Medical Associates Commercial |
$16.71
|
| Rate for Payer: Midlands Choice Commercial |
$15.60
|
| Rate for Payer: United Healthcare Commercial |
$20.05
|
|
|
ketorolac 15 mg/mL 1ml Inj SDV [VDMC]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.05
|
| Rate for Payer: Aetna of IA Medicare |
$12.70
|
| Rate for Payer: Amerigroup Medicaid |
$12.85
|
| Rate for Payer: Amerigroup Medicare |
$10.13
|
| Rate for Payer: Cash Price |
$17.83
|
| Rate for Payer: Cash Price |
$17.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.03
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.73
|
| Rate for Payer: Medical Associates Commercial |
$16.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.03
|
| Rate for Payer: Midlands Choice Commercial |
$15.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.53
|
| Rate for Payer: United Healthcare Commercial |
$20.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.15
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ketorolac 30 mg/mL Inj 1ml SDV [VDMC]
|
Facility
|
OP
|
$26.44
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$23.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.80
|
| Rate for Payer: Aetna of IA Medicare |
$15.07
|
| Rate for Payer: Amerigroup Medicaid |
$15.25
|
| Rate for Payer: Amerigroup Medicare |
$12.02
|
| Rate for Payer: Cash Price |
$21.15
|
| Rate for Payer: Cash Price |
$21.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.83
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.10
|
| Rate for Payer: Medical Associates Commercial |
$19.83
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.90
|
| Rate for Payer: Midlands Choice Commercial |
$18.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.68
|
| Rate for Payer: United Healthcare Commercial |
$23.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.60
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ketorolac 30 mg/mL Inj 1ml SDV [VDMC]
|
Facility
|
IP
|
$26.44
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.51 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna of IA Commercial |
$23.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.80
|
| Rate for Payer: Cash Price |
$21.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.83
|
| Rate for Payer: Medical Associates Commercial |
$19.83
|
| Rate for Payer: Midlands Choice Commercial |
$18.51
|
| Rate for Payer: United Healthcare Commercial |
$23.80
|
|
|
ketorolac 60 mg/mL 2 ml SDV inj [VDMC]
|
Facility
|
OP
|
$23.23
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.90
|
| Rate for Payer: Aetna of IA Medicare |
$13.24
|
| Rate for Payer: Amerigroup Medicaid |
$13.40
|
| Rate for Payer: Amerigroup Medicare |
$10.56
|
| Rate for Payer: Cash Price |
$18.58
|
| Rate for Payer: Cash Price |
$18.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.27
|
| Rate for Payer: Medical Associates Commercial |
$17.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.45
|
| Rate for Payer: Midlands Choice Commercial |
$16.26
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.02
|
| Rate for Payer: United Healthcare Commercial |
$20.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.70
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ketorolac 60 mg/mL 2 ml SDV inj [VDMC]
|
Facility
|
IP
|
$23.23
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.26 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Aetna of IA Commercial |
$20.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.90
|
| Rate for Payer: Cash Price |
$18.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.42
|
| Rate for Payer: Medical Associates Commercial |
$17.42
|
| Rate for Payer: Midlands Choice Commercial |
$16.26
|
| Rate for Payer: United Healthcare Commercial |
$20.90
|
|
|
ketotifen 0.025% 5 ml Ophth Sol [VDMC]
|
Facility
|
IP
|
$41.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.04 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna of IA Commercial |
$37.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.33
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.11
|
| Rate for Payer: Medical Associates Commercial |
$31.11
|
| Rate for Payer: Midlands Choice Commercial |
$29.04
|
| Rate for Payer: United Healthcare Commercial |
$37.33
|
|
|
ketotifen 0.025% 5 ml Ophth Sol [VDMC]
|
Facility
|
OP
|
$41.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna of IA Commercial |
$37.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.33
|
| Rate for Payer: Aetna of IA Medicare |
$23.64
|
| Rate for Payer: Amerigroup Medicaid |
$23.93
|
| Rate for Payer: Amerigroup Medicare |
$18.85
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.11
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.69
|
| Rate for Payer: Medical Associates Commercial |
$31.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.67
|
| Rate for Payer: Midlands Choice Commercial |
$29.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.47
|
| Rate for Payer: United Healthcare Commercial |
$37.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.47
|
|
