|
MG Mammogram Digital Diagnostic Bilat.
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
CPT 77066 50
|
| Hospital Charge Code |
969799
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$150.75 |
| Max. Negotiated Rate |
$301.50 |
| Rate for Payer: Aetna of IA Commercial |
$301.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$301.50
|
| Rate for Payer: Aetna of IA Medicare |
$190.95
|
| Rate for Payer: Amerigroup Medicaid |
$193.23
|
| Rate for Payer: Amerigroup Medicare |
$152.26
|
| Rate for Payer: Cash Price |
$268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$251.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$150.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$191.35
|
| Rate for Payer: Medical Associates Commercial |
$251.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$150.75
|
| Rate for Payer: Midlands Choice Commercial |
$234.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$194.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$173.36
|
| Rate for Payer: United Healthcare Commercial |
$301.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$197.65
|
|
|
MG Mammogram Digital Diagnostic Bilat.
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
CPT 77066 50
|
| Hospital Charge Code |
969799
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$234.50 |
| Max. Negotiated Rate |
$301.50 |
| Rate for Payer: Aetna of IA Commercial |
$301.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$301.50
|
| Rate for Payer: Cash Price |
$268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$251.25
|
| Rate for Payer: Medical Associates Commercial |
$251.25
|
| Rate for Payer: Midlands Choice Commercial |
$234.50
|
| Rate for Payer: United Healthcare Commercial |
$301.50
|
|
|
MG Mammogram Digital Diagnostic Left.
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
969801
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$264.60 |
| Rate for Payer: Aetna of IA Commercial |
$264.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$264.60
|
| Rate for Payer: Aetna of IA Medicare |
$167.58
|
| Rate for Payer: Amerigroup Medicaid |
$169.58
|
| Rate for Payer: Amerigroup Medicare |
$133.62
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$220.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$132.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$167.93
|
| Rate for Payer: Medical Associates Commercial |
$220.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$132.30
|
| Rate for Payer: Midlands Choice Commercial |
$205.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$170.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$152.15
|
| Rate for Payer: United Healthcare Commercial |
$264.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$173.46
|
|
|
MG Mammogram Digital Diagnostic Left.
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
969801
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$205.80 |
| Max. Negotiated Rate |
$264.60 |
| Rate for Payer: Aetna of IA Commercial |
$264.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$264.60
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$220.50
|
| Rate for Payer: Medical Associates Commercial |
$220.50
|
| Rate for Payer: Midlands Choice Commercial |
$205.80
|
| Rate for Payer: United Healthcare Commercial |
$264.60
|
|
|
MG Mammogram Digital Diagnostic Right.
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
969803
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$264.60 |
| Rate for Payer: Aetna of IA Commercial |
$264.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$264.60
|
| Rate for Payer: Aetna of IA Medicare |
$167.58
|
| Rate for Payer: Amerigroup Medicaid |
$169.58
|
| Rate for Payer: Amerigroup Medicare |
$133.62
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$220.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$132.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$167.93
|
| Rate for Payer: Medical Associates Commercial |
$220.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$132.30
|
| Rate for Payer: Midlands Choice Commercial |
$205.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$170.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$152.15
|
| Rate for Payer: United Healthcare Commercial |
$264.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$173.46
|
|
|
MG Mammogram Digital Diagnostic Right.
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
969803
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$205.80 |
| Max. Negotiated Rate |
$264.60 |
| Rate for Payer: Aetna of IA Commercial |
$264.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$264.60
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$220.50
|
| Rate for Payer: Medical Associates Commercial |
$220.50
|
| Rate for Payer: Midlands Choice Commercial |
$205.80
|
| Rate for Payer: United Healthcare Commercial |
$264.60
|
|
|
MG Mammogram Digital Screening Bilat.
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
969805
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$211.40 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Bilat.
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
969805
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Aetna of IA Medicare |
$172.14
|
| Rate for Payer: Amerigroup Medicaid |
$174.19
|
| Rate for Payer: Amerigroup Medicare |
$137.26
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.90
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$175.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$156.28
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Left.
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52|LT
|
| Hospital Charge Code |
4570784
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$211.40 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Left.
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52|LT
|
| Hospital Charge Code |
4570784
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Aetna of IA Medicare |
$172.14
|
| Rate for Payer: Amerigroup Medicaid |
$174.19
|
| Rate for Payer: Amerigroup Medicare |
$137.26
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.90
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$175.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$156.28
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Right.
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
4570787
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$211.40 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Right.
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
4570787
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Aetna of IA Medicare |
$172.14
|
| Rate for Payer: Amerigroup Medicaid |
$174.19
|
| Rate for Payer: Amerigroup Medicare |
$137.26
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.90
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$175.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$156.28
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
miconazole Top 2% Crm 15gm [VDMC]
|
Facility
|
IP
|
$16.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Aetna of IA Commercial |
$14.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.41
|
| Rate for Payer: Cash Price |
$12.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.01
|
| Rate for Payer: Medical Associates Commercial |
$12.01
|
| Rate for Payer: Midlands Choice Commercial |
$11.21
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
|
|
miconazole Top 2% Crm 15gm [VDMC]
|
Facility
|
OP
|
$16.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436187
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.21 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Aetna of IA Commercial |
$14.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.41
|
| Rate for Payer: Aetna of IA Medicare |
$9.13
|
| Rate for Payer: Amerigroup Medicaid |
$9.24
|
| Rate for Payer: Amerigroup Medicare |
$7.28
|
| Rate for Payer: Cash Price |
$12.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.15
|
| Rate for Payer: Medical Associates Commercial |
$12.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.21
|
| Rate for Payer: Midlands Choice Commercial |
$11.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.29
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.45
|
|
|
miconazole topical 2% Cre 45 gm [VDMC]
|
Facility
|
OP
|
$43.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.54 |
| Max. Negotiated Rate |
$39.08 |
| Rate for Payer: Aetna of IA Commercial |
$39.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.08
|
| Rate for Payer: Aetna of IA Medicare |
$24.75
|
| Rate for Payer: Amerigroup Medicaid |
$25.05
|
| Rate for Payer: Amerigroup Medicare |
$19.74
|
| Rate for Payer: Cash Price |
$34.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.57
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.80
|
| Rate for Payer: Medical Associates Commercial |
$32.57
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.54
|
| Rate for Payer: Midlands Choice Commercial |
$30.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.47
|
| Rate for Payer: United Healthcare Commercial |
$39.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.62
|
|
|
miconazole topical 2% Cre 45 gm [VDMC]
|
Facility
|
IP
|
$43.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$39.08 |
| Rate for Payer: Aetna of IA Commercial |
$39.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.08
|
| Rate for Payer: Cash Price |
$34.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.57
|
| Rate for Payer: Medical Associates Commercial |
$32.57
|
| Rate for Payer: Midlands Choice Commercial |
$30.40
|
| Rate for Payer: United Healthcare Commercial |
$39.08
|
|
|
midazolam 1 mg/mL 2 ML SDV [VDMC]
|
Facility
|
OP
|
$41.09
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10406011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.49 |
| Max. Negotiated Rate |
$36.98 |
| Rate for Payer: Aetna of IA Commercial |
$36.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.98
|
| Rate for Payer: Aetna of IA Medicare |
$23.42
|
| Rate for Payer: Amerigroup Medicaid |
$23.70
|
| Rate for Payer: Amerigroup Medicare |
$18.67
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.82
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.47
|
| Rate for Payer: Medical Associates Commercial |
$30.82
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.49
|
| Rate for Payer: Midlands Choice Commercial |
$28.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.26
|
| Rate for Payer: United Healthcare Commercial |
$36.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.24
|
|
|
midazolam 1 mg/mL 2 ML SDV [VDMC]
|
Facility
|
IP
|
$41.09
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10406011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.76 |
| Max. Negotiated Rate |
$36.98 |
| Rate for Payer: Aetna of IA Commercial |
$36.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.98
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.82
|
| Rate for Payer: Medical Associates Commercial |
$30.82
|
| Rate for Payer: Midlands Choice Commercial |
$28.76
|
| Rate for Payer: United Healthcare Commercial |
$36.98
|
|
|
midazolam 1 mg/mL Inj 5 ML SDV [VDMC]
|
Facility
|
IP
|
$42.87
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10405940
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.01 |
| Max. Negotiated Rate |
$38.58 |
| Rate for Payer: Aetna of IA Commercial |
$38.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.58
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.15
|
| Rate for Payer: Medical Associates Commercial |
$32.15
|
| Rate for Payer: Midlands Choice Commercial |
$30.01
|
| Rate for Payer: United Healthcare Commercial |
$38.58
|
|
|
midazolam 1 mg/mL Inj 5 ML SDV [VDMC]
|
Facility
|
OP
|
$42.87
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
10405940
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$38.58 |
| Rate for Payer: Aetna of IA Commercial |
$38.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.58
|
| Rate for Payer: Aetna of IA Medicare |
$24.44
|
| Rate for Payer: Amerigroup Medicaid |
$24.73
|
| Rate for Payer: Amerigroup Medicare |
$19.49
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.29
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.49
|
| Rate for Payer: Medical Associates Commercial |
$32.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.29
|
| Rate for Payer: Midlands Choice Commercial |
$30.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.19
|
| Rate for Payer: United Healthcare Commercial |
$38.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.29
|
|
|
midazolam 1 mg/mL MDV 5 ML vial [VDMC]
|
Facility
|
OP
|
$43.61
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
13683949
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.63 |
| Max. Negotiated Rate |
$39.25 |
| Rate for Payer: Aetna of IA Commercial |
$39.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.25
|
| Rate for Payer: Aetna of IA Medicare |
$24.86
|
| Rate for Payer: Amerigroup Medicaid |
$25.16
|
| Rate for Payer: Amerigroup Medicare |
$19.82
|
| Rate for Payer: Cash Price |
$34.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.91
|
| Rate for Payer: Medical Associates Commercial |
$32.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.63
|
| Rate for Payer: Midlands Choice Commercial |
$30.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.57
|
| Rate for Payer: United Healthcare Commercial |
$39.25
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.73
|
|
|
midazolam 1 mg/mL MDV 5 ML vial [VDMC]
|
Facility
|
IP
|
$43.61
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
13683949
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.53 |
| Max. Negotiated Rate |
$39.25 |
| Rate for Payer: Aetna of IA Commercial |
$39.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.25
|
| Rate for Payer: Cash Price |
$34.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.71
|
| Rate for Payer: Medical Associates Commercial |
$32.71
|
| Rate for Payer: Midlands Choice Commercial |
$30.53
|
| Rate for Payer: United Healthcare Commercial |
$39.25
|
|
|
midazolam 2 mg/mL Oral Syrup [VDMC]
|
Facility
|
IP
|
$10.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$9.01 |
| Rate for Payer: Aetna of IA Commercial |
$9.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.01
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.51
|
| Rate for Payer: Medical Associates Commercial |
$7.51
|
| Rate for Payer: Midlands Choice Commercial |
$7.00
|
| Rate for Payer: United Healthcare Commercial |
$9.01
|
|
|
midazolam 2 mg/mL Oral Syrup [VDMC]
|
Facility
|
OP
|
$10.01
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$9.01 |
| Rate for Payer: Aetna of IA Commercial |
$9.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.01
|
| Rate for Payer: Aetna of IA Medicare |
$5.70
|
| Rate for Payer: Amerigroup Medicaid |
$5.77
|
| Rate for Payer: Amerigroup Medicare |
$4.55
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.72
|
| Rate for Payer: Medical Associates Commercial |
$7.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.50
|
| Rate for Payer: Midlands Choice Commercial |
$7.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.18
|
| Rate for Payer: United Healthcare Commercial |
$9.01
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.90
|
|
|
midodrine 5 mg Tab [VDMC]
|
Facility
|
OP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10406147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Aetna of IA Medicare |
$1.28
|
| Rate for Payer: Amerigroup Medicaid |
$1.30
|
| Rate for Payer: Amerigroup Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.28
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.01
|
| Rate for Payer: Midlands Choice Commercial |
$1.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
