|
olmesartan 20 mg Tab [VDMC]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410207
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of IA Commercial |
$1.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.16
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.74
|
| Rate for Payer: Medical Associates Commercial |
$0.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.67
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.76
|
|
|
omalizumab 150 mg/mL syringe SDS [VDMC]
|
Facility
|
IP
|
$2,932.24
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
18591016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,052.57 |
| Max. Negotiated Rate |
$2,639.02 |
| Rate for Payer: Aetna of IA Commercial |
$2,639.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,639.02
|
| Rate for Payer: Cash Price |
$2,345.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,199.18
|
| Rate for Payer: Medical Associates Commercial |
$2,199.18
|
| Rate for Payer: Midlands Choice Commercial |
$2,052.57
|
| Rate for Payer: United Healthcare Commercial |
$2,639.02
|
|
|
omalizumab 150 mg/mL syringe SDS [VDMC]
|
Facility
|
OP
|
$2,932.24
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
18591016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,319.51 |
| Max. Negotiated Rate |
$2,639.02 |
| Rate for Payer: Aetna of IA Commercial |
$2,639.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,639.02
|
| Rate for Payer: Aetna of IA Medicare |
$1,671.38
|
| Rate for Payer: Amerigroup Medicaid |
$1,691.32
|
| Rate for Payer: Amerigroup Medicare |
$1,332.70
|
| Rate for Payer: Cash Price |
$2,345.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,199.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,319.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,674.90
|
| Rate for Payer: Medical Associates Commercial |
$2,199.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,319.51
|
| Rate for Payer: Midlands Choice Commercial |
$2,052.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,699.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,517.43
|
| Rate for Payer: United Healthcare Commercial |
$2,639.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,730.02
|
|
|
omalizumab 300 mg/2 mL syringe SDS [VDMC]
|
Facility
|
OP
|
$5,764.48
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
28363553
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,594.02 |
| Max. Negotiated Rate |
$5,188.03 |
| Rate for Payer: Aetna of IA Commercial |
$5,188.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,188.03
|
| Rate for Payer: Aetna of IA Medicare |
$3,285.75
|
| Rate for Payer: Amerigroup Medicaid |
$3,324.95
|
| Rate for Payer: Amerigroup Medicare |
$2,619.96
|
| Rate for Payer: Cash Price |
$4,611.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,323.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,594.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,292.67
|
| Rate for Payer: Medical Associates Commercial |
$4,323.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,594.02
|
| Rate for Payer: Midlands Choice Commercial |
$4,035.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,341.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,983.12
|
| Rate for Payer: United Healthcare Commercial |
$5,188.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,401.04
|
|
|
omalizumab 300 mg/2 mL syringe SDS [VDMC]
|
Facility
|
IP
|
$5,764.48
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
28363553
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,035.14 |
| Max. Negotiated Rate |
$5,188.03 |
| Rate for Payer: Aetna of IA Commercial |
$5,188.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,188.03
|
| Rate for Payer: Cash Price |
$4,611.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,323.36
|
| Rate for Payer: Medical Associates Commercial |
$4,323.36
|
| Rate for Payer: Midlands Choice Commercial |
$4,035.14
|
| Rate for Payer: United Healthcare Commercial |
$5,188.03
|
|
|
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 |
$668.23 |
| 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 |
$856.52
|
| Rate for Payer: Amerigroup Medicare |
$674.91
|
| 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 |
$668.23
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$848.21
|
| Rate for Payer: Medical Associates Commercial |
$1,113.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$668.23
|
| Rate for Payer: Midlands Choice Commercial |
$1,039.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$860.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$768.47
|
| Rate for Payer: United Healthcare Commercial |
$1,336.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$876.13
|
|
|
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
|
|
|
omega-3 polyunsaturated fatty acids ethyl esters 1000 mg oral capsule [VDMC]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of IA Commercial |
$1.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.48
|
| Rate for Payer: Aetna of IA Medicare |
$0.94
|
| Rate for Payer: Amerigroup Medicaid |
$0.95
|
| Rate for Payer: Amerigroup Medicare |
$0.75
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.23
|
| 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 |
$0.94
|
| Rate for Payer: Medical Associates Commercial |
$1.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.74
|
| Rate for Payer: Midlands Choice Commercial |
$1.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.97
|
|
|
omega-3 polyunsaturated fatty acids ethyl esters 1000 mg oral capsule [VDMC]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of IA Commercial |
$1.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.48
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.23
|
| Rate for Payer: Medical Associates Commercial |
$1.23
|
| Rate for Payer: Midlands Choice Commercial |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
|
|
OMEGA 4.75MM PEEK KNOTLESS ANCHOR SYSTEM
|
Facility
|
IP
|
$765.00
|
|
|
Service Code
|
HCPCS 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
|
|
|
OMEGA 4.75MM PEEK KNOTLESS ANCHOR SYSTEM
|
Facility
|
OP
|
$765.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8771316
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$344.25 |
| 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 |
$441.25
|
| Rate for Payer: Amerigroup Medicare |
$347.69
|
| 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 |
$344.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$436.97
|
| Rate for Payer: Medical Associates Commercial |
$573.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$344.25
|
| Rate for Payer: Midlands Choice Commercial |
$535.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$443.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$395.89
|
| Rate for Payer: United Healthcare Commercial |
$688.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$451.35
|
|
|
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
|
|
|
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 |
$0.67 |
| 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 |
$0.85
|
| Rate for Payer: Amerigroup Medicare |
$0.67
|
| 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 |
$0.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.85
|
| Rate for Payer: Medical Associates Commercial |
$1.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.67
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.77
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.87
|
|
|
onabotulinumtoxinA 100 units Pow [VDMC]
|
Facility
|
OP
|
$1,368.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
10410416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$615.60 |
| Max. Negotiated Rate |
$1,231.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,231.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,231.20
|
| Rate for Payer: Aetna of IA Medicare |
$779.76
|
| Rate for Payer: Amerigroup Medicaid |
$789.06
|
| Rate for Payer: Amerigroup Medicare |
$621.76
|
| Rate for Payer: Cash Price |
$1,094.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,026.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$615.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$781.40
|
| Rate for Payer: Medical Associates Commercial |
$1,026.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$615.60
|
| Rate for Payer: Midlands Choice Commercial |
$957.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$792.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$707.94
|
| Rate for Payer: United Healthcare Commercial |
$1,231.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$807.12
|
|
|
onabotulinumtoxinA 100 units Pow [VDMC]
|
Facility
|
IP
|
$1,368.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
10410416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$957.60 |
| Max. Negotiated Rate |
$1,231.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,231.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,231.20
|
| Rate for Payer: Cash Price |
$1,094.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,026.00
|
| Rate for Payer: Medical Associates Commercial |
$1,026.00
|
| Rate for Payer: Midlands Choice Commercial |
$957.60
|
| Rate for Payer: United Healthcare Commercial |
$1,231.20
|
|
|
ondansetron 2 mg/mL 2 ML Inj SDV [VDMC]
|
Facility
|
IP
|
$20.96
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
10410483
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$18.87 |
| Rate for Payer: Aetna of IA Commercial |
$18.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.87
|
| Rate for Payer: Cash Price |
$16.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.72
|
| Rate for Payer: Medical Associates Commercial |
$15.72
|
| Rate for Payer: Midlands Choice Commercial |
$14.67
|
| Rate for Payer: United Healthcare Commercial |
$18.87
|
|
|
ondansetron 2 mg/mL 2 ML Inj SDV [VDMC]
|
Facility
|
OP
|
$20.96
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
10410483
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.43 |
| Max. Negotiated Rate |
$18.87 |
| Rate for Payer: Aetna of IA Commercial |
$18.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.87
|
| Rate for Payer: Aetna of IA Medicare |
$11.95
|
| Rate for Payer: Amerigroup Medicaid |
$12.09
|
| Rate for Payer: Amerigroup Medicare |
$9.53
|
| Rate for Payer: Cash Price |
$16.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.97
|
| Rate for Payer: Medical Associates Commercial |
$15.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.43
|
| Rate for Payer: Midlands Choice Commercial |
$14.67
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.85
|
| Rate for Payer: United Healthcare Commercial |
$18.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$12.37
|
|
|
ondansetron 4 mg Dis Tab [VDMC]
|
Facility
|
OP
|
$2.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna of IA Commercial |
$2.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.13
|
| Rate for Payer: Aetna of IA Medicare |
$1.35
|
| Rate for Payer: Amerigroup Medicaid |
$1.37
|
| Rate for Payer: Amerigroup Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.07
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.35
|
| Rate for Payer: Medical Associates Commercial |
$1.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.07
|
| Rate for Payer: Midlands Choice Commercial |
$1.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.22
|
| Rate for Payer: United Healthcare Commercial |
$2.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.40
|
|
|
ondansetron 4 mg Dis Tab [VDMC]
|
Facility
|
IP
|
$2.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10410554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna of IA Commercial |
$2.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.13
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.78
|
| Rate for Payer: Medical Associates Commercial |
$1.78
|
| Rate for Payer: Midlands Choice Commercial |
$1.66
|
| Rate for Payer: United Healthcare Commercial |
$2.13
|
|
|
Ongoing
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
CPT 93668
|
| Hospital Charge Code |
8663517
|
|
Hospital Revenue Code
|
943
|
| Min. Negotiated Rate |
$64.35 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Aetna of IA Medicare |
$81.51
|
| Rate for Payer: Amerigroup Medicaid |
$82.48
|
| Rate for Payer: Amerigroup Medicare |
$64.99
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.68
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.35
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$74.00
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.37
|
|
|
Ongoing
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
CPT 93668
|
| Hospital Charge Code |
8663517
|
|
Hospital Revenue Code
|
943
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
|
|
Ongoing - KX
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
CPT 93668 KX
|
| Hospital Charge Code |
8663516
|
|
Hospital Revenue Code
|
943
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
|
|
Ongoing - KX
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
CPT 93668 KX
|
| Hospital Charge Code |
8663516
|
|
Hospital Revenue Code
|
943
|
| Min. Negotiated Rate |
$64.35 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: Aetna of IA Commercial |
$128.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.70
|
| Rate for Payer: Aetna of IA Medicare |
$81.51
|
| Rate for Payer: Amerigroup Medicaid |
$82.48
|
| Rate for Payer: Amerigroup Medicare |
$64.99
|
| Rate for Payer: Cash Price |
$114.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.68
|
| Rate for Payer: Medical Associates Commercial |
$107.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.35
|
| Rate for Payer: Midlands Choice Commercial |
$100.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$74.00
|
| Rate for Payer: United Healthcare Commercial |
$128.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.37
|
|
|
ophthalmic irrigation, extraocular - Sol [VDMC]
|
Facility
|
IP
|
$29.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11223386
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.66 |
| Max. Negotiated Rate |
$26.57 |
| Rate for Payer: Aetna of IA Commercial |
$26.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.57
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.14
|
| Rate for Payer: Medical Associates Commercial |
$22.14
|
| Rate for Payer: Midlands Choice Commercial |
$20.66
|
| Rate for Payer: United Healthcare Commercial |
$26.57
|
|
|
ophthalmic irrigation, extraocular - Sol [VDMC]
|
Facility
|
OP
|
$29.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11223386
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$26.57 |
| Rate for Payer: Aetna of IA Commercial |
$26.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.57
|
| Rate for Payer: Aetna of IA Medicare |
$16.83
|
| Rate for Payer: Amerigroup Medicaid |
$17.03
|
| Rate for Payer: Amerigroup Medicare |
$13.42
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.86
|
| Rate for Payer: Medical Associates Commercial |
$22.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.28
|
| Rate for Payer: Midlands Choice Commercial |
$20.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.28
|
| Rate for Payer: United Healthcare Commercial |
$26.57
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.42
|
|
