|
Level 6
|
Facility
|
IP
|
$8,068.00
|
|
| Hospital Charge Code |
1378482
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,647.60 |
| Max. Negotiated Rate |
$7,261.20 |
| Rate for Payer: Aetna of IA Commercial |
$7,261.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,261.20
|
| Rate for Payer: Cash Price |
$6,454.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,051.00
|
| Rate for Payer: Medical Associates Commercial |
$6,051.00
|
| Rate for Payer: Midlands Choice Commercial |
$5,647.60
|
| Rate for Payer: United Healthcare Commercial |
$7,261.20
|
|
|
Level 6
|
Facility
|
OP
|
$8,068.00
|
|
| Hospital Charge Code |
1378482
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,630.60 |
| Max. Negotiated Rate |
$7,261.20 |
| Rate for Payer: Aetna of IA Commercial |
$7,261.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,261.20
|
| Rate for Payer: Aetna of IA Medicare |
$4,598.76
|
| Rate for Payer: Amerigroup Medicaid |
$4,653.62
|
| Rate for Payer: Amerigroup Medicare |
$3,666.91
|
| Rate for Payer: Cash Price |
$6,454.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,051.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,630.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,608.44
|
| Rate for Payer: Medical Associates Commercial |
$6,051.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,630.60
|
| Rate for Payer: Midlands Choice Commercial |
$5,647.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,676.21
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,175.19
|
| Rate for Payer: United Healthcare Commercial |
$7,261.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,760.12
|
|
|
Level 6: Per Additional Intervals (30 Min)
|
Facility
|
IP
|
$403.00
|
|
| Hospital Charge Code |
1378482
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$282.10 |
| Max. Negotiated Rate |
$362.70 |
| Rate for Payer: Aetna of IA Commercial |
$362.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$362.70
|
| Rate for Payer: Cash Price |
$322.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$302.25
|
| Rate for Payer: Medical Associates Commercial |
$302.25
|
| Rate for Payer: Midlands Choice Commercial |
$282.10
|
| Rate for Payer: United Healthcare Commercial |
$362.70
|
|
|
Level 6: Per Additional Intervals (30 Min)
|
Facility
|
OP
|
$403.00
|
|
| Hospital Charge Code |
1378482
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$181.35 |
| Max. Negotiated Rate |
$362.70 |
| Rate for Payer: Aetna of IA Commercial |
$362.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$362.70
|
| Rate for Payer: Aetna of IA Medicare |
$229.71
|
| Rate for Payer: Amerigroup Medicaid |
$232.45
|
| Rate for Payer: Amerigroup Medicare |
$183.16
|
| Rate for Payer: Cash Price |
$322.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$302.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$181.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$230.19
|
| Rate for Payer: Medical Associates Commercial |
$302.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$181.35
|
| Rate for Payer: Midlands Choice Commercial |
$282.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$233.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$208.55
|
| Rate for Payer: United Healthcare Commercial |
$362.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$237.77
|
|
|
levETIRAcetam 100 mg/mL 5ml cup Oral Sol [VDMC]
|
Facility
|
IP
|
$13.70
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399512
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Aetna of IA Commercial |
$12.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.33
|
| Rate for Payer: Cash Price |
$10.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.27
|
| Rate for Payer: Medical Associates Commercial |
$10.27
|
| Rate for Payer: Midlands Choice Commercial |
$9.59
|
| Rate for Payer: United Healthcare Commercial |
$12.33
|
|
|
levETIRAcetam 100 mg/mL 5ml cup Oral Sol [VDMC]
|
Facility
|
OP
|
$13.70
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399512
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.16 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Aetna of IA Commercial |
$12.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.33
|
| Rate for Payer: Aetna of IA Medicare |
$7.81
|
| Rate for Payer: Amerigroup Medicaid |
$7.90
|
| Rate for Payer: Amerigroup Medicare |
$6.22
|
| Rate for Payer: Cash Price |
$10.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.27
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.82
|
| Rate for Payer: Medical Associates Commercial |
$10.27
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.16
|
| Rate for Payer: Midlands Choice Commercial |
$9.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.09
|
| Rate for Payer: United Healthcare Commercial |
$12.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.08
|
|
|
levETIRAcetam 500 mg/5ml Vial [VDMC]
|
Facility
|
IP
|
$24.33
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
11263874
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$21.89 |
| Rate for Payer: Aetna of IA Commercial |
$21.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.89
|
| Rate for Payer: Cash Price |
$19.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.24
|
| Rate for Payer: Medical Associates Commercial |
$18.24
|
| Rate for Payer: Midlands Choice Commercial |
$17.03
|
| Rate for Payer: United Healthcare Commercial |
$21.89
|
|
|
levETIRAcetam 500 mg/5ml Vial [VDMC]
|
Facility
|
OP
|
$24.33
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
11263874
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.95 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$21.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.89
|
| Rate for Payer: Aetna of IA Medicare |
$13.87
|
| Rate for Payer: Amerigroup Medicaid |
$14.03
|
| Rate for Payer: Amerigroup Medicare |
$11.06
|
| Rate for Payer: Cash Price |
$19.46
|
| Rate for Payer: Cash Price |
$19.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.90
|
| Rate for Payer: Medical Associates Commercial |
$18.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.95
|
| Rate for Payer: Midlands Choice Commercial |
$17.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.59
|
| Rate for Payer: United Healthcare Commercial |
$21.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.35
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
levETIRAcetam 500 mg Tab [VDMC]
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of IA Commercial |
$1.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.37
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.14
|
| Rate for Payer: Medical Associates Commercial |
$1.14
|
| Rate for Payer: Midlands Choice Commercial |
$1.07
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
|
|
levETIRAcetam 500 mg Tab [VDMC]
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399579
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of IA Commercial |
$1.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.37
|
| Rate for Payer: Aetna of IA Medicare |
$0.87
|
| Rate for Payer: Amerigroup Medicaid |
$0.88
|
| Rate for Payer: Amerigroup Medicare |
$0.69
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.69
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.87
|
| Rate for Payer: Medical Associates Commercial |
$1.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.69
|
| Rate for Payer: Midlands Choice Commercial |
$1.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.90
|
|
|
levofloxacin 250 mg/50 mL IV Sol [VDMC]
|
Facility
|
OP
|
$55.11
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
10399648
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$24.80 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$49.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.60
|
| Rate for Payer: Aetna of IA Medicare |
$31.41
|
| Rate for Payer: Amerigroup Medicaid |
$31.79
|
| Rate for Payer: Amerigroup Medicare |
$25.05
|
| Rate for Payer: Cash Price |
$44.09
|
| Rate for Payer: Cash Price |
$44.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.48
|
| Rate for Payer: Medical Associates Commercial |
$41.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.80
|
| Rate for Payer: Midlands Choice Commercial |
$38.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$28.52
|
| Rate for Payer: United Healthcare Commercial |
$49.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$32.52
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
levofloxacin 250 mg/50 mL IV Sol [VDMC]
|
Facility
|
IP
|
$55.11
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
10399648
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$49.60 |
| Rate for Payer: Aetna of IA Commercial |
$49.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.60
|
| Rate for Payer: Cash Price |
$44.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.33
|
| Rate for Payer: Medical Associates Commercial |
$41.33
|
| Rate for Payer: Midlands Choice Commercial |
$38.58
|
| Rate for Payer: United Healthcare Commercial |
$49.60
|
|
|
levofloxacin 500 mg/100 mL IV Sol [VDMC]
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
10399719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$84.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$84.60
|
| Rate for Payer: Aetna of IA Medicare |
$53.58
|
| Rate for Payer: Amerigroup Medicaid |
$54.22
|
| Rate for Payer: Amerigroup Medicare |
$42.72
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$70.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$42.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$53.69
|
| Rate for Payer: Medical Associates Commercial |
$70.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$42.30
|
| Rate for Payer: Midlands Choice Commercial |
$65.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$48.64
|
| Rate for Payer: United Healthcare Commercial |
$84.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$55.46
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
levofloxacin 500 mg/100 mL IV Sol [VDMC]
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
10399719
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna of IA Commercial |
$84.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$84.60
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$70.50
|
| Rate for Payer: Medical Associates Commercial |
$70.50
|
| Rate for Payer: Midlands Choice Commercial |
$65.80
|
| Rate for Payer: United Healthcare Commercial |
$84.60
|
|
|
levofloxacin 500 mg Tab UD [VDMC]
|
Facility
|
IP
|
$1.73
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11224623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of IA Commercial |
$1.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.56
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.30
|
| Rate for Payer: Medical Associates Commercial |
$1.30
|
| Rate for Payer: Midlands Choice Commercial |
$1.21
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
|
|
levofloxacin 500 mg Tab UD [VDMC]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11224623
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of IA Commercial |
$1.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.56
|
| Rate for Payer: Aetna of IA Medicare |
$0.99
|
| Rate for Payer: Amerigroup Medicaid |
$1.00
|
| Rate for Payer: Amerigroup Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.99
|
| Rate for Payer: Medical Associates Commercial |
$1.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.78
|
| Rate for Payer: Midlands Choice Commercial |
$1.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.02
|
|
|
levofloxacin 750 mg/150 mL IV Sol [VDMC]
|
Facility
|
IP
|
$58.23
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
10399790
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$52.40 |
| Rate for Payer: Aetna of IA Commercial |
$52.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.40
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.67
|
| Rate for Payer: Medical Associates Commercial |
$43.67
|
| Rate for Payer: Midlands Choice Commercial |
$40.76
|
| Rate for Payer: United Healthcare Commercial |
$52.40
|
|
|
levofloxacin 750 mg/150 mL IV Sol [VDMC]
|
Facility
|
OP
|
$58.23
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
10399790
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.20 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$52.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.40
|
| Rate for Payer: Aetna of IA Medicare |
$33.19
|
| Rate for Payer: Amerigroup Medicaid |
$33.58
|
| Rate for Payer: Amerigroup Medicare |
$26.46
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.67
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.26
|
| Rate for Payer: Medical Associates Commercial |
$43.67
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.20
|
| Rate for Payer: Midlands Choice Commercial |
$40.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.13
|
| Rate for Payer: United Healthcare Commercial |
$52.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.35
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
levonorgestrel 13.5 mg Dev[VDMC]
|
Facility
|
OP
|
$1,613.74
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
12484629
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$726.18 |
| Max. Negotiated Rate |
$1,452.37 |
| Rate for Payer: Aetna of IA Commercial |
$1,452.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,452.37
|
| Rate for Payer: Aetna of IA Medicare |
$919.83
|
| Rate for Payer: Amerigroup Medicaid |
$930.81
|
| Rate for Payer: Amerigroup Medicare |
$733.44
|
| Rate for Payer: Cash Price |
$1,290.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,210.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$726.18
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$921.77
|
| Rate for Payer: Medical Associates Commercial |
$1,210.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$726.18
|
| Rate for Payer: Midlands Choice Commercial |
$1,129.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$935.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$835.11
|
| Rate for Payer: United Healthcare Commercial |
$1,452.37
|
| Rate for Payer: United Healthcare Managed Medicare |
$952.11
|
|
|
levonorgestrel 13.5 mg Dev[VDMC]
|
Facility
|
IP
|
$1,613.74
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
12484629
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,129.62 |
| Max. Negotiated Rate |
$1,452.37 |
| Rate for Payer: Aetna of IA Commercial |
$1,452.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,452.37
|
| Rate for Payer: Cash Price |
$1,290.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,210.30
|
| Rate for Payer: Medical Associates Commercial |
$1,210.30
|
| Rate for Payer: Midlands Choice Commercial |
$1,129.62
|
| Rate for Payer: United Healthcare Commercial |
$1,452.37
|
|
|
levonorgestrel 1.5 mg Tab [VDMC]
|
Facility
|
OP
|
$12.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399861
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.47 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna of IA Commercial |
$10.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.94
|
| Rate for Payer: Aetna of IA Medicare |
$6.93
|
| Rate for Payer: Amerigroup Medicaid |
$7.01
|
| Rate for Payer: Amerigroup Medicare |
$5.53
|
| Rate for Payer: Cash Price |
$9.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.95
|
| Rate for Payer: Medical Associates Commercial |
$9.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.47
|
| Rate for Payer: Midlands Choice Commercial |
$8.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.29
|
| Rate for Payer: United Healthcare Commercial |
$10.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.17
|
|
|
levonorgestrel 1.5 mg Tab [VDMC]
|
Facility
|
IP
|
$12.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10399861
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna of IA Commercial |
$10.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.94
|
| Rate for Payer: Cash Price |
$9.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.12
|
| Rate for Payer: Medical Associates Commercial |
$9.12
|
| Rate for Payer: Midlands Choice Commercial |
$8.51
|
| Rate for Payer: United Healthcare Commercial |
$10.94
|
|
|
levonorgestrel 52 mg Dev 3 yrs [VDMC]
|
Facility
|
IP
|
$3,388.40
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
12564888
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,371.88 |
| Max. Negotiated Rate |
$3,049.56 |
| Rate for Payer: Aetna of IA Commercial |
$3,049.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,049.56
|
| Rate for Payer: Cash Price |
$2,710.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,541.30
|
| Rate for Payer: Medical Associates Commercial |
$2,541.30
|
| Rate for Payer: Midlands Choice Commercial |
$2,371.88
|
| Rate for Payer: United Healthcare Commercial |
$3,049.56
|
|
|
levonorgestrel 52 mg Dev 3 yrs [VDMC]
|
Facility
|
OP
|
$3,388.40
|
|
|
Service Code
|
HCPCS J7297
|
| Hospital Charge Code |
12564888
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,524.78 |
| Max. Negotiated Rate |
$3,049.56 |
| Rate for Payer: Aetna of IA Commercial |
$3,049.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,049.56
|
| Rate for Payer: Aetna of IA Medicare |
$1,931.39
|
| Rate for Payer: Amerigroup Medicaid |
$1,954.43
|
| Rate for Payer: Amerigroup Medicare |
$1,540.03
|
| Rate for Payer: Cash Price |
$2,710.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,541.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,524.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,935.45
|
| Rate for Payer: Medical Associates Commercial |
$2,541.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,524.78
|
| Rate for Payer: Midlands Choice Commercial |
$2,371.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,963.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,753.50
|
| Rate for Payer: United Healthcare Commercial |
$3,049.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,999.16
|
|
|
levonorgestrel 52 mg Dev 5 yrs [VDMC]
|
Facility
|
OP
|
$2,274.76
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
12564524
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,023.64 |
| Max. Negotiated Rate |
$2,047.28 |
| Rate for Payer: Aetna of IA Commercial |
$2,047.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,047.28
|
| Rate for Payer: Aetna of IA Medicare |
$1,296.61
|
| Rate for Payer: Amerigroup Medicaid |
$1,312.08
|
| Rate for Payer: Amerigroup Medicare |
$1,033.88
|
| Rate for Payer: Cash Price |
$1,819.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,706.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,023.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,299.34
|
| Rate for Payer: Medical Associates Commercial |
$1,706.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,023.64
|
| Rate for Payer: Midlands Choice Commercial |
$1,592.33
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,318.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,177.19
|
| Rate for Payer: United Healthcare Commercial |
$2,047.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,342.11
|
|
