|
methylphenidate 5 mg Tab [VDMC]
|
Facility
|
OP
|
$3.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10404703
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Aetna of IA Commercial |
$3.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.03
|
| Rate for Payer: Aetna of IA Medicare |
$1.92
|
| Rate for Payer: Amerigroup Medicaid |
$1.94
|
| Rate for Payer: Amerigroup Medicare |
$1.53
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.53
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.92
|
| Rate for Payer: Medical Associates Commercial |
$2.53
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.52
|
| Rate for Payer: Midlands Choice Commercial |
$2.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.99
|
|
|
methylPREDNISolone 125 mg preservative-free Pow [VDMC]
|
Facility
|
IP
|
$50.46
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
10404839
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.32 |
| Max. Negotiated Rate |
$45.42 |
| Rate for Payer: Aetna of IA Commercial |
$45.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.42
|
| Rate for Payer: Cash Price |
$40.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.85
|
| Rate for Payer: Medical Associates Commercial |
$37.85
|
| Rate for Payer: Midlands Choice Commercial |
$35.32
|
| Rate for Payer: United Healthcare Commercial |
$45.42
|
|
|
methylPREDNISolone 125 mg preservative-free Pow [VDMC]
|
Facility
|
OP
|
$50.46
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
10404839
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.71 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$45.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.42
|
| Rate for Payer: Aetna of IA Medicare |
$28.76
|
| Rate for Payer: Amerigroup Medicaid |
$29.11
|
| Rate for Payer: Amerigroup Medicare |
$22.94
|
| Rate for Payer: Cash Price |
$40.37
|
| Rate for Payer: Cash Price |
$40.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.71
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.83
|
| Rate for Payer: Medical Associates Commercial |
$37.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.71
|
| Rate for Payer: Midlands Choice Commercial |
$35.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.12
|
| Rate for Payer: United Healthcare Commercial |
$45.42
|
| Rate for Payer: United Healthcare Managed Medicare |
$29.77
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
methylPREDNISolone 1gm PF SDV Pow [VDMC]
|
Facility
|
OP
|
$242.88
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
10404772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$109.30 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$218.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$218.59
|
| Rate for Payer: Aetna of IA Medicare |
$138.44
|
| Rate for Payer: Amerigroup Medicaid |
$140.09
|
| Rate for Payer: Amerigroup Medicare |
$110.39
|
| Rate for Payer: Cash Price |
$194.30
|
| Rate for Payer: Cash Price |
$194.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$182.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$109.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$138.73
|
| Rate for Payer: Medical Associates Commercial |
$182.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$109.30
|
| Rate for Payer: Midlands Choice Commercial |
$170.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$140.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$125.69
|
| Rate for Payer: United Healthcare Commercial |
$218.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$143.30
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
methylPREDNISolone 1gm PF SDV Pow [VDMC]
|
Facility
|
IP
|
$242.88
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
10404772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$170.02 |
| Max. Negotiated Rate |
$218.59 |
| Rate for Payer: Aetna of IA Commercial |
$218.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$218.59
|
| Rate for Payer: Cash Price |
$194.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$182.16
|
| Rate for Payer: Medical Associates Commercial |
$182.16
|
| Rate for Payer: Midlands Choice Commercial |
$170.02
|
| Rate for Payer: United Healthcare Commercial |
$218.59
|
|
|
methylPREDNISolone 40 mg preservative-free Pow [VDMC]
|
Facility
|
IP
|
$37.92
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
10405053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.55 |
| Max. Negotiated Rate |
$34.13 |
| Rate for Payer: Aetna of IA Commercial |
$34.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.13
|
| Rate for Payer: Cash Price |
$30.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.44
|
| Rate for Payer: Medical Associates Commercial |
$28.44
|
| Rate for Payer: Midlands Choice Commercial |
$26.55
|
| Rate for Payer: United Healthcare Commercial |
$34.13
|
|
|
methylPREDNISolone 40 mg preservative-free Pow [VDMC]
|
Facility
|
OP
|
$37.92
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
10405053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.06 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$34.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.13
|
| Rate for Payer: Aetna of IA Medicare |
$21.62
|
| Rate for Payer: Amerigroup Medicaid |
$21.87
|
| Rate for Payer: Amerigroup Medicare |
$17.24
|
| Rate for Payer: Cash Price |
$30.34
|
| Rate for Payer: Cash Price |
$30.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.66
|
| Rate for Payer: Medical Associates Commercial |
$28.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.06
|
| Rate for Payer: Midlands Choice Commercial |
$26.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.62
|
| Rate for Payer: United Healthcare Commercial |
$34.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.37
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
methylPREDNISolone 4 mg Tab [VDMC]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
HCPCS J7509
|
| Hospital Charge Code |
11518853
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna of IA Commercial |
$1.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.41
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.17
|
| Rate for Payer: Medical Associates Commercial |
$1.17
|
| Rate for Payer: Midlands Choice Commercial |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
|
|
methylPREDNISolone 4 mg Tab [VDMC]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
HCPCS J7509
|
| Hospital Charge Code |
11518853
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$1.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.41
|
| Rate for Payer: Aetna of IA Medicare |
$0.89
|
| Rate for Payer: Amerigroup Medicaid |
$0.90
|
| Rate for Payer: Amerigroup Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.17
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$1.17
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.70
|
| Rate for Payer: Midlands Choice Commercial |
$1.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.81
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.92
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
methylPREDNISolone 80 mg/mL 1 ml Inj Susp [VDMC]
|
Facility
|
IP
|
$51.16
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
10405114
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.81 |
| Max. Negotiated Rate |
$46.04 |
| Rate for Payer: Aetna of IA Commercial |
$46.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.04
|
| Rate for Payer: Cash Price |
$40.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.37
|
| Rate for Payer: Medical Associates Commercial |
$38.37
|
| Rate for Payer: Midlands Choice Commercial |
$35.81
|
| Rate for Payer: United Healthcare Commercial |
$46.04
|
|
|
methylPREDNISolone 80 mg/mL 1 ml Inj Susp [VDMC]
|
Facility
|
OP
|
$51.16
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
10405114
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$46.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.04
|
| Rate for Payer: Aetna of IA Medicare |
$29.16
|
| Rate for Payer: Amerigroup Medicaid |
$29.51
|
| Rate for Payer: Amerigroup Medicare |
$23.25
|
| Rate for Payer: Cash Price |
$40.93
|
| Rate for Payer: Cash Price |
$40.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.37
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$29.22
|
| Rate for Payer: Medical Associates Commercial |
$38.37
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.02
|
| Rate for Payer: Midlands Choice Commercial |
$35.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.48
|
| Rate for Payer: United Healthcare Commercial |
$46.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.18
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
metoclopramide 10mg Tab [VDMC]
|
Facility
|
IP
|
$1.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10429709
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of IA Commercial |
$1.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.05
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
|
|
metoclopramide 10mg Tab [VDMC]
|
Facility
|
OP
|
$1.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10429709
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of IA Commercial |
$1.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.05
|
| Rate for Payer: Aetna of IA Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicaid |
$0.67
|
| Rate for Payer: Amerigroup Medicare |
$0.53
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.53
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.67
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.53
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.60
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.69
|
|
|
metoclopramide 5 mg/5 mL Oral Syrup [VDMC]
|
Facility
|
OP
|
$7.58
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10429642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$6.82 |
| Rate for Payer: Aetna of IA Commercial |
$6.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.82
|
| Rate for Payer: Aetna of IA Medicare |
$4.32
|
| Rate for Payer: Amerigroup Medicaid |
$4.37
|
| Rate for Payer: Amerigroup Medicare |
$3.44
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.33
|
| Rate for Payer: Medical Associates Commercial |
$5.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.41
|
| Rate for Payer: Midlands Choice Commercial |
$5.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.92
|
| Rate for Payer: United Healthcare Commercial |
$6.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.47
|
|
|
metoclopramide 5 mg/5 mL Oral Syrup [VDMC]
|
Facility
|
IP
|
$7.58
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10429642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$6.82 |
| Rate for Payer: Aetna of IA Commercial |
$6.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.82
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.68
|
| Rate for Payer: Medical Associates Commercial |
$5.68
|
| Rate for Payer: Midlands Choice Commercial |
$5.31
|
| Rate for Payer: United Healthcare Commercial |
$6.82
|
|
|
metoclopramide 5 mg/mL 2 ML Inj Sol [VDMC]
|
Facility
|
OP
|
$23.86
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
10405183
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$21.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.48
|
| Rate for Payer: Aetna of IA Medicare |
$13.60
|
| Rate for Payer: Amerigroup Medicaid |
$13.76
|
| Rate for Payer: Amerigroup Medicare |
$10.85
|
| Rate for Payer: Cash Price |
$19.09
|
| Rate for Payer: Cash Price |
$19.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.63
|
| Rate for Payer: Medical Associates Commercial |
$17.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.74
|
| Rate for Payer: Midlands Choice Commercial |
$16.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.35
|
| Rate for Payer: United Healthcare Commercial |
$21.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.08
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
metoclopramide 5 mg/mL 2 ML Inj Sol [VDMC]
|
Facility
|
IP
|
$23.86
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
10405183
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.70 |
| Max. Negotiated Rate |
$21.48 |
| Rate for Payer: Aetna of IA Commercial |
$21.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.48
|
| Rate for Payer: Cash Price |
$19.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.90
|
| Rate for Payer: Medical Associates Commercial |
$17.90
|
| Rate for Payer: Midlands Choice Commercial |
$16.70
|
| Rate for Payer: United Healthcare Commercial |
$21.48
|
|
|
metolazone 5 mg Tab [VDMC]
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10405323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Aetna of IA Commercial |
$1.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.89
|
| Rate for Payer: Aetna of IA Medicare |
$1.20
|
| Rate for Payer: Amerigroup Medicaid |
$1.21
|
| Rate for Payer: Amerigroup Medicare |
$0.96
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.20
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.95
|
| Rate for Payer: Midlands Choice Commercial |
$1.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.24
|
|
|
metolazone 5 mg Tab [VDMC]
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10405323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Aetna of IA Commercial |
$1.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.89
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Midlands Choice Commercial |
$1.47
|
| Rate for Payer: United Healthcare Commercial |
$1.89
|
|
|
metoprolol 5 mg/5mL SDV Inj Sol [VDMC]
|
Facility
|
OP
|
$21.88
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10405392
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.84 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna of IA Commercial |
$19.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.69
|
| Rate for Payer: Aetna of IA Medicare |
$12.47
|
| Rate for Payer: Amerigroup Medicaid |
$12.62
|
| Rate for Payer: Amerigroup Medicare |
$9.94
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.41
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.50
|
| Rate for Payer: Medical Associates Commercial |
$16.41
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.84
|
| Rate for Payer: Midlands Choice Commercial |
$15.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.32
|
| Rate for Payer: United Healthcare Commercial |
$19.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$12.91
|
|
|
metoprolol 5 mg/5mL SDV Inj Sol [VDMC]
|
Facility
|
IP
|
$21.88
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10405392
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.31 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna of IA Commercial |
$19.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.69
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.41
|
| Rate for Payer: Medical Associates Commercial |
$16.41
|
| Rate for Payer: Midlands Choice Commercial |
$15.31
|
| Rate for Payer: United Healthcare Commercial |
$19.69
|
|
|
metoprolol SUC XL 24 HR 25 mg ER Tab [VDMC]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10405463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of IA Commercial |
$1.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.95
|
| Rate for Payer: Aetna of IA Medicare |
$1.24
|
| Rate for Payer: Amerigroup Medicaid |
$1.25
|
| Rate for Payer: Amerigroup Medicare |
$0.99
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.63
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.24
|
| Rate for Payer: Medical Associates Commercial |
$1.63
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.98
|
| Rate for Payer: Midlands Choice Commercial |
$1.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.28
|
|
|
metoprolol SUC XL 24 HR 25 mg ER Tab [VDMC]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10405463
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of IA Commercial |
$1.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.95
|
| Rate for Payer: Cash Price |
$1.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.63
|
| Rate for Payer: Medical Associates Commercial |
$1.63
|
| Rate for Payer: Midlands Choice Commercial |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
|
|
metoprolol SUC XL 24 HR 50 mg ER Tab [VDMC]
|
Facility
|
IP
|
$1.94
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10405534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of IA Commercial |
$1.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.75
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.46
|
| Rate for Payer: Medical Associates Commercial |
$1.46
|
| Rate for Payer: Midlands Choice Commercial |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$1.75
|
|
|
metoprolol SUC XL 24 HR 50 mg ER Tab [VDMC]
|
Facility
|
OP
|
$1.94
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10405534
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of IA Commercial |
$1.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.75
|
| Rate for Payer: Aetna of IA Medicare |
$1.11
|
| Rate for Payer: Amerigroup Medicaid |
$1.12
|
| Rate for Payer: Amerigroup Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.46
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.11
|
| Rate for Payer: Medical Associates Commercial |
$1.46
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.87
|
| Rate for Payer: Midlands Choice Commercial |
$1.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$1.75
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.15
|
|
