|
OLANZapine 5 mg Tab [VDMC]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Cash Price |
$1.69
|
| 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 |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
|
|
OLIGOCLONAL BANDING
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
8093941
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of IA Commercial |
$147.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$147.60
|
| Rate for Payer: Aetna of IA Medicare |
$93.48
|
| Rate for Payer: Amerigroup Medicaid |
$82.77
|
| Rate for Payer: Amerigroup Medicare |
$82.82
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$123.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$82.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.97
|
| Rate for Payer: Medical Associates Commercial |
$123.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$82.00
|
| Rate for Payer: Midlands Choice Commercial |
$114.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$83.23
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$83.18
|
| Rate for Payer: Oscar Health of IA Commercial |
$123.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$123.00
|
| Rate for Payer: United Healthcare Commercial |
$147.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$96.76
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
OLIGOCLONAL BANDING
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
8093941
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of IA Commercial |
$147.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$147.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$123.00
|
| Rate for Payer: Medical Associates Commercial |
$123.00
|
| Rate for Payer: Midlands Choice Commercial |
$114.80
|
| Rate for Payer: United Healthcare Commercial |
$147.60
|
|
|
Oligoclonal Band Profile DMCL
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
8037734
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of IA Commercial |
$147.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$147.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$123.00
|
| Rate for Payer: Medical Associates Commercial |
$123.00
|
| Rate for Payer: Midlands Choice Commercial |
$114.80
|
| Rate for Payer: United Healthcare Commercial |
$147.60
|
|
|
Oligoclonal Band Profile DMCL
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
8037734
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of IA Commercial |
$147.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$147.60
|
| Rate for Payer: Aetna of IA Medicare |
$93.48
|
| Rate for Payer: Amerigroup Medicaid |
$82.77
|
| Rate for Payer: Amerigroup Medicare |
$82.82
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$123.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$82.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.97
|
| Rate for Payer: Medical Associates Commercial |
$123.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$82.00
|
| Rate for Payer: Midlands Choice Commercial |
$114.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$83.23
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$83.18
|
| Rate for Payer: Oscar Health of IA Commercial |
$123.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$123.00
|
| Rate for Payer: United Healthcare Commercial |
$147.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$96.76
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
OLIVE WIRE 0.062
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8759904
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of IA Commercial |
$48.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.60
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.50
|
| Rate for Payer: Medical Associates Commercial |
$40.50
|
| Rate for Payer: Midlands Choice Commercial |
$37.80
|
| Rate for Payer: United Healthcare Commercial |
$48.60
|
|
|
OLIVE WIRE 0.062
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8759904
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26.99 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of IA Commercial |
$48.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.60
|
| Rate for Payer: Aetna of IA Medicare |
$30.78
|
| Rate for Payer: Amerigroup Medicaid |
$27.25
|
| Rate for Payer: Amerigroup Medicare |
$27.27
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.99
|
| Rate for Payer: Medical Associates Commercial |
$40.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.00
|
| Rate for Payer: Midlands Choice Commercial |
$37.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.40
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$27.39
|
| Rate for Payer: Oscar Health of IA Commercial |
$40.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.50
|
| Rate for Payer: United Healthcare Commercial |
$48.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.86
|
|
|
OLIVE WIRE 1.4MM
|
Facility
|
IP
|
$172.00
|
|
| Hospital Charge Code |
8047370
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$120.40 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of IA Commercial |
$154.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$154.80
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$129.00
|
| Rate for Payer: Medical Associates Commercial |
$129.00
|
| Rate for Payer: Midlands Choice Commercial |
$120.40
|
| Rate for Payer: United Healthcare Commercial |
$154.80
|
|
|
OLIVE WIRE 1.4MM
|
Facility
|
OP
|
$172.00
|
|
| Hospital Charge Code |
8047370
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$85.97 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of IA Commercial |
$154.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$154.80
|
| Rate for Payer: Aetna of IA Medicare |
$98.04
|
| Rate for Payer: Amerigroup Medicaid |
$86.81
|
| Rate for Payer: Amerigroup Medicare |
$86.86
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$129.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$86.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$85.97
|
| Rate for Payer: Medical Associates Commercial |
$129.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$86.00
|
| Rate for Payer: Midlands Choice Commercial |
$120.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$87.29
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$87.24
|
| Rate for Payer: Oscar Health of IA Commercial |
$129.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$129.00
|
| Rate for Payer: United Healthcare Commercial |
$154.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$101.48
|
|
|
OLIVE WIRE ARSENAL ANKLE .062" X 3"
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8895437
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26.99 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of IA Commercial |
$48.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.60
|
| Rate for Payer: Aetna of IA Medicare |
$30.78
|
| Rate for Payer: Amerigroup Medicaid |
$27.25
|
| Rate for Payer: Amerigroup Medicare |
$27.27
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.99
|
| Rate for Payer: Medical Associates Commercial |
$40.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.00
|
| Rate for Payer: Midlands Choice Commercial |
$37.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.40
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$27.39
|
| Rate for Payer: Oscar Health of IA Commercial |
$40.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.50
|
| Rate for Payer: United Healthcare Commercial |
$48.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.86
|
|
|
OLIVE WIRE ARSENAL ANKLE .062" X 3"
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8895437
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of IA Commercial |
$48.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.60
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.50
|
| Rate for Payer: Medical Associates Commercial |
$40.50
|
| Rate for Payer: Midlands Choice Commercial |
$37.80
|
| Rate for Payer: United Healthcare Commercial |
$48.60
|
|
|
olmesartan 20 mg Tab [VDMC]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410207
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of IA Commercial |
$1.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.21
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Midlands Choice Commercial |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
|
olmesartan 20 mg Tab [VDMC]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410207
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of IA Commercial |
$1.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.21
|
| Rate for Payer: Aetna of IA Medicare |
$0.76
|
| Rate for Payer: Amerigroup Medicaid |
$0.68
|
| Rate for Payer: Amerigroup Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.67
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.67
|
| Rate for Payer: Midlands Choice Commercial |
$0.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.68
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.68
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.79
|
|
|
omalizumab 150 mg/mL syringe SDS [VDMC]
|
Facility
|
IP
|
$2,869.92
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
18591016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,008.94 |
| Max. Negotiated Rate |
$2,582.93 |
| Rate for Payer: Aetna of IA Commercial |
$2,582.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,582.93
|
| Rate for Payer: Cash Price |
$2,295.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,152.44
|
| Rate for Payer: Medical Associates Commercial |
$2,152.44
|
| Rate for Payer: Midlands Choice Commercial |
$2,008.94
|
| Rate for Payer: United Healthcare Commercial |
$2,582.93
|
|
|
omalizumab 150 mg/mL syringe SDS [VDMC]
|
Facility
|
OP
|
$2,869.92
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
18591016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,434.39 |
| Max. Negotiated Rate |
$2,582.93 |
| Rate for Payer: Aetna of IA Commercial |
$2,582.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,582.93
|
| Rate for Payer: Aetna of IA Medicare |
$1,635.85
|
| Rate for Payer: Amerigroup Medicaid |
$1,448.45
|
| Rate for Payer: Amerigroup Medicare |
$1,449.31
|
| Rate for Payer: Cash Price |
$2,295.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,152.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,434.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,434.39
|
| Rate for Payer: Medical Associates Commercial |
$2,152.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,434.96
|
| Rate for Payer: Midlands Choice Commercial |
$2,008.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,456.48
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1,455.62
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,152.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,152.44
|
| Rate for Payer: United Healthcare Commercial |
$2,582.93
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,693.25
|
|
|
omalizumab 75 mg/0.5 mL syringe SDS [VDMC]
|
Facility
|
IP
|
$1,484.96
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
26003865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,039.47 |
| Max. Negotiated Rate |
$1,336.46 |
| Rate for Payer: Aetna of IA Commercial |
$1,336.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,336.46
|
| Rate for Payer: Cash Price |
$1,187.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,113.72
|
| Rate for Payer: Medical Associates Commercial |
$1,113.72
|
| Rate for Payer: Midlands Choice Commercial |
$1,039.47
|
| Rate for Payer: United Healthcare Commercial |
$1,336.46
|
|
|
omalizumab 75 mg/0.5 mL syringe SDS [VDMC]
|
Facility
|
OP
|
$1,484.96
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
26003865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$742.18 |
| Max. Negotiated Rate |
$1,336.46 |
| Rate for Payer: Aetna of IA Commercial |
$1,336.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,336.46
|
| Rate for Payer: Aetna of IA Medicare |
$846.43
|
| Rate for Payer: Amerigroup Medicaid |
$749.46
|
| Rate for Payer: Amerigroup Medicare |
$749.90
|
| Rate for Payer: Cash Price |
$1,187.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,113.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$742.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$742.18
|
| Rate for Payer: Medical Associates Commercial |
$1,113.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$742.48
|
| Rate for Payer: Midlands Choice Commercial |
$1,039.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$753.62
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$753.17
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,113.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,113.72
|
| Rate for Payer: United Healthcare Commercial |
$1,336.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$876.13
|
|
|
omega-3 polyunsaturated fatty acids ethyl esters 1000 mg oral capsule [VDMC]
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| 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: Aetna of IA Medicare |
$0.89
|
| Rate for Payer: Amerigroup Medicaid |
$0.79
|
| Rate for Payer: Amerigroup Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.79
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.78
|
| Rate for Payer: Medical Associates Commercial |
$1.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.79
|
| Rate for Payer: Midlands Choice Commercial |
$1.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.80
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.80
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.93
|
|
|
omega-3 polyunsaturated fatty acids ethyl esters 1000 mg oral capsule [VDMC]
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| 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 |
$1.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.18
|
| Rate for Payer: Medical Associates Commercial |
$1.18
|
| Rate for Payer: Midlands Choice Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
|
|
OMEGA 4.75MM PEEK KNOTLESS ANCHOR SYSTEM
|
Facility
|
OP
|
$765.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8771316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$382.35 |
| Max. Negotiated Rate |
$688.50 |
| Rate for Payer: Aetna of IA Commercial |
$688.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$688.50
|
| Rate for Payer: Aetna of IA Medicare |
$436.05
|
| Rate for Payer: Amerigroup Medicaid |
$386.10
|
| Rate for Payer: Amerigroup Medicare |
$386.32
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$573.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$382.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$382.35
|
| Rate for Payer: Medical Associates Commercial |
$573.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$382.50
|
| Rate for Payer: Midlands Choice Commercial |
$535.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$388.24
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$388.01
|
| Rate for Payer: Oscar Health of IA Commercial |
$573.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$573.75
|
| Rate for Payer: United Healthcare Commercial |
$688.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$451.35
|
|
|
OMEGA 4.75MM PEEK KNOTLESS ANCHOR SYSTEM
|
Facility
|
IP
|
$765.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8771316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$688.50 |
| Rate for Payer: Aetna of IA Commercial |
$688.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$688.50
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$573.75
|
| Rate for Payer: Medical Associates Commercial |
$573.75
|
| Rate for Payer: Midlands Choice Commercial |
$535.50
|
| Rate for Payer: United Healthcare Commercial |
$688.50
|
|
|
omeprazole 20 mg Oral DR Cap [VDMC]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410347
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of IA Commercial |
$1.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.33
|
| Rate for Payer: Aetna of IA Medicare |
$0.84
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.75
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.11
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.74
|
| Rate for Payer: Medical Associates Commercial |
$1.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.74
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.75
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.87
|
|
|
omeprazole 20 mg Oral DR Cap [VDMC]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410347
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of IA Commercial |
$1.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.33
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.11
|
| Rate for Payer: Medical Associates Commercial |
$1.11
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
|
|
onabotulinumtoxinA 100 units Pow [VDMC]
|
Facility
|
OP
|
$1,302.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
10410416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$650.74 |
| Max. Negotiated Rate |
$1,171.80 |
| Rate for Payer: Aetna of IA Commercial |
$1,171.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,171.80
|
| Rate for Payer: Aetna of IA Medicare |
$742.14
|
| Rate for Payer: Amerigroup Medicaid |
$657.12
|
| Rate for Payer: Amerigroup Medicare |
$657.51
|
| Rate for Payer: Cash Price |
$1,041.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$976.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$651.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$650.74
|
| Rate for Payer: Medical Associates Commercial |
$976.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$651.00
|
| Rate for Payer: Midlands Choice Commercial |
$911.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$660.76
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$660.37
|
| Rate for Payer: Oscar Health of IA Commercial |
$976.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$976.50
|
| Rate for Payer: United Healthcare Commercial |
$1,171.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$768.18
|
|
|
onabotulinumtoxinA 100 units Pow [VDMC]
|
Facility
|
IP
|
$1,302.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
10410416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$911.40 |
| Max. Negotiated Rate |
$1,171.80 |
| Rate for Payer: Aetna of IA Commercial |
$1,171.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,171.80
|
| Rate for Payer: Cash Price |
$1,041.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$976.50
|
| Rate for Payer: Medical Associates Commercial |
$976.50
|
| Rate for Payer: Midlands Choice Commercial |
$911.40
|
| Rate for Payer: United Healthcare Commercial |
$1,171.80
|
|
