|
nicotine 7 mg/24 hr Transderm ER Film [VDMC]
|
Facility
|
OP
|
$12.26
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$11.03 |
| Rate for Payer: Aetna of IA Commercial |
$11.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.03
|
| Rate for Payer: Aetna of IA Medicare |
$6.99
|
| Rate for Payer: Amerigroup Medicaid |
$7.07
|
| Rate for Payer: Amerigroup Medicare |
$5.57
|
| Rate for Payer: Cash Price |
$9.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.00
|
| Rate for Payer: Medical Associates Commercial |
$9.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.52
|
| Rate for Payer: Midlands Choice Commercial |
$8.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.34
|
| Rate for Payer: United Healthcare Commercial |
$11.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.23
|
|
|
nicotine 7 mg/24 hr Transderm ER Film [VDMC]
|
Facility
|
IP
|
$12.26
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408605
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$11.03 |
| Rate for Payer: Aetna of IA Commercial |
$11.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.03
|
| Rate for Payer: Cash Price |
$9.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.20
|
| Rate for Payer: Medical Associates Commercial |
$9.20
|
| Rate for Payer: Midlands Choice Commercial |
$8.58
|
| Rate for Payer: United Healthcare Commercial |
$11.03
|
|
|
Nicotine and Metabolites UR DMCL
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 80323
|
| Hospital Charge Code |
8822401
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna of IA Commercial |
$108.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$108.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$90.00
|
| Rate for Payer: Medical Associates Commercial |
$90.00
|
| Rate for Payer: Midlands Choice Commercial |
$84.00
|
| Rate for Payer: United Healthcare Commercial |
$108.00
|
|
|
Nicotine and Metabolites UR DMCL
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 80323
|
| Hospital Charge Code |
8822401
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$43.25 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna of IA Commercial |
$108.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$108.00
|
| Rate for Payer: Aetna of IA Medicare |
$68.40
|
| Rate for Payer: Amerigroup Medicaid |
$69.22
|
| Rate for Payer: Amerigroup Medicare |
$54.54
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$90.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$68.54
|
| Rate for Payer: Medical Associates Commercial |
$90.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.00
|
| Rate for Payer: Midlands Choice Commercial |
$84.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$69.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$62.10
|
| Rate for Payer: United Healthcare Commercial |
$108.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.80
|
| Rate for Payer: Wellmark IA HMO WHPI |
$43.25
|
| Rate for Payer: Wellmark IA PPO |
$47.64
|
|
|
NIFEdipine 10 mg Cap [VDMC]
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408670
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of IA Commercial |
$2.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.12
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.77
|
| Rate for Payer: Medical Associates Commercial |
$1.77
|
| Rate for Payer: Midlands Choice Commercial |
$1.65
|
| Rate for Payer: United Healthcare Commercial |
$2.12
|
|
|
NIFEdipine 10 mg Cap [VDMC]
|
Facility
|
OP
|
$2.35
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408670
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of IA Commercial |
$2.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.12
|
| Rate for Payer: Aetna of IA Medicare |
$1.34
|
| Rate for Payer: Amerigroup Medicaid |
$1.36
|
| Rate for Payer: Amerigroup Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.77
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.34
|
| Rate for Payer: Medical Associates Commercial |
$1.77
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.06
|
| Rate for Payer: Midlands Choice Commercial |
$1.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.22
|
| Rate for Payer: United Healthcare Commercial |
$2.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.39
|
|
|
NIFEdipine 30 mg ER Tab [VDMC]
|
Facility
|
IP
|
$3.47
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408739
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna of IA Commercial |
$3.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.12
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.60
|
| Rate for Payer: Medical Associates Commercial |
$2.60
|
| Rate for Payer: Midlands Choice Commercial |
$2.43
|
| Rate for Payer: United Healthcare Commercial |
$3.12
|
|
|
NIFEdipine 30 mg ER Tab [VDMC]
|
Facility
|
OP
|
$3.47
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408739
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna of IA Commercial |
$3.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.12
|
| Rate for Payer: Aetna of IA Medicare |
$1.98
|
| Rate for Payer: Amerigroup Medicaid |
$2.00
|
| Rate for Payer: Amerigroup Medicare |
$1.58
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.98
|
| Rate for Payer: Medical Associates Commercial |
$2.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.56
|
| Rate for Payer: Midlands Choice Commercial |
$2.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.79
|
| Rate for Payer: United Healthcare Commercial |
$3.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.05
|
|
|
nitrofurantoin macrocrystals 50 mg Cap [VDMC]
|
Facility
|
OP
|
$3.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408808
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna of IA Commercial |
$2.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.83
|
| Rate for Payer: Aetna of IA Medicare |
$1.79
|
| Rate for Payer: Amerigroup Medicaid |
$1.81
|
| Rate for Payer: Amerigroup Medicare |
$1.43
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.80
|
| Rate for Payer: Medical Associates Commercial |
$2.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.42
|
| Rate for Payer: Midlands Choice Commercial |
$2.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.63
|
| Rate for Payer: United Healthcare Commercial |
$2.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.86
|
|
|
nitrofurantoin macrocrystals 50 mg Cap [VDMC]
|
Facility
|
IP
|
$3.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408808
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna of IA Commercial |
$2.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.83
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.36
|
| Rate for Payer: Medical Associates Commercial |
$2.36
|
| Rate for Payer: Midlands Choice Commercial |
$2.20
|
| Rate for Payer: United Healthcare Commercial |
$2.83
|
|
|
nitroglycerin 0.1 mg/hr Fil [VDMC]
|
Facility
|
OP
|
$9.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna of IA Commercial |
$8.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.90
|
| Rate for Payer: Aetna of IA Medicare |
$5.64
|
| Rate for Payer: Amerigroup Medicaid |
$5.70
|
| Rate for Payer: Amerigroup Medicare |
$4.50
|
| Rate for Payer: Cash Price |
$7.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.65
|
| Rate for Payer: Medical Associates Commercial |
$7.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.45
|
| Rate for Payer: Midlands Choice Commercial |
$6.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$8.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.84
|
|
|
nitroglycerin 0.1 mg/hr Fil [VDMC]
|
Facility
|
IP
|
$9.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.92 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna of IA Commercial |
$8.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.90
|
| Rate for Payer: Cash Price |
$7.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.42
|
| Rate for Payer: Medical Associates Commercial |
$7.42
|
| Rate for Payer: Midlands Choice Commercial |
$6.92
|
| Rate for Payer: United Healthcare Commercial |
$8.90
|
|
|
nitroglycerin 0.2 mg/hr Transderm ER Film [VDMC]
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408877
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$9.04 |
| Rate for Payer: Aetna of IA Commercial |
$9.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.04
|
| Rate for Payer: Aetna of IA Medicare |
$5.73
|
| Rate for Payer: Amerigroup Medicaid |
$5.79
|
| Rate for Payer: Amerigroup Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.53
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.74
|
| Rate for Payer: Medical Associates Commercial |
$7.53
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.52
|
| Rate for Payer: Midlands Choice Commercial |
$7.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.20
|
| Rate for Payer: United Healthcare Commercial |
$9.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.93
|
|
|
nitroglycerin 0.2 mg/hr Transderm ER Film [VDMC]
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408877
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$9.04 |
| Rate for Payer: Aetna of IA Commercial |
$9.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.04
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.53
|
| Rate for Payer: Medical Associates Commercial |
$7.53
|
| Rate for Payer: Midlands Choice Commercial |
$7.03
|
| Rate for Payer: United Healthcare Commercial |
$9.04
|
|
|
nitroglycerin 0.4 mg Spr MDV [VDMC]
|
Facility
|
IP
|
$16.89
|
|
|
Service Code
|
NDC 45802-0210-01
|
| Hospital Charge Code |
22142517
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.82 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Aetna of IA Commercial |
$15.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.20
|
| Rate for Payer: Cash Price |
$13.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.66
|
| Rate for Payer: Medical Associates Commercial |
$12.66
|
| Rate for Payer: Midlands Choice Commercial |
$11.82
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
|
|
nitroglycerin 0.4 mg Spr MDV [VDMC]
|
Facility
|
OP
|
$16.89
|
|
|
Service Code
|
NDC 45802-0210-01
|
| Hospital Charge Code |
22142517
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Aetna of IA Commercial |
$15.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.20
|
| Rate for Payer: Aetna of IA Medicare |
$9.63
|
| Rate for Payer: Amerigroup Medicaid |
$9.74
|
| Rate for Payer: Amerigroup Medicare |
$7.67
|
| Rate for Payer: Cash Price |
$13.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.65
|
| Rate for Payer: Medical Associates Commercial |
$12.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.60
|
| Rate for Payer: Midlands Choice Commercial |
$11.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.74
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.96
|
|
|
nitroglycerin 0.4 mg sublingual Tab [VDMC]
|
Facility
|
IP
|
$78.85
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408946
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.20 |
| Max. Negotiated Rate |
$70.96 |
| Rate for Payer: Aetna of IA Commercial |
$70.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.96
|
| Rate for Payer: Cash Price |
$63.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$59.14
|
| Rate for Payer: Medical Associates Commercial |
$59.14
|
| Rate for Payer: Midlands Choice Commercial |
$55.20
|
| Rate for Payer: United Healthcare Commercial |
$70.96
|
|
|
nitroglycerin 0.4 mg sublingual Tab [VDMC]
|
Facility
|
OP
|
$78.85
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10408946
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$70.96 |
| Rate for Payer: Aetna of IA Commercial |
$70.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.96
|
| Rate for Payer: Aetna of IA Medicare |
$44.94
|
| Rate for Payer: Amerigroup Medicaid |
$45.48
|
| Rate for Payer: Amerigroup Medicare |
$35.84
|
| Rate for Payer: Cash Price |
$63.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$59.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$35.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$45.04
|
| Rate for Payer: Medical Associates Commercial |
$59.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$35.48
|
| Rate for Payer: Midlands Choice Commercial |
$55.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$45.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.80
|
| Rate for Payer: United Healthcare Commercial |
$70.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$46.52
|
|
|
nitroglycerin 10 mg/100 mL-D5W IV Sol [VDMC]
|
Facility
|
OP
|
$125.37
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
10409074
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.42 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$112.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$112.83
|
| Rate for Payer: Aetna of IA Medicare |
$71.46
|
| Rate for Payer: Amerigroup Medicaid |
$72.31
|
| Rate for Payer: Amerigroup Medicare |
$56.98
|
| Rate for Payer: Cash Price |
$100.30
|
| Rate for Payer: Cash Price |
$100.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$94.03
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$56.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$71.61
|
| Rate for Payer: Medical Associates Commercial |
$94.03
|
| Rate for Payer: Medical Associates Managed Medicare |
$56.42
|
| Rate for Payer: Midlands Choice Commercial |
$87.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$72.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$64.88
|
| Rate for Payer: United Healthcare Commercial |
$112.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$73.97
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
nitroglycerin 10 mg/100 mL-D5W IV Sol [VDMC]
|
Facility
|
IP
|
$125.37
|
|
|
Service Code
|
HCPCS J2305
|
| Hospital Charge Code |
10409074
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$87.76 |
| Max. Negotiated Rate |
$112.83 |
| Rate for Payer: Aetna of IA Commercial |
$112.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$112.83
|
| Rate for Payer: Cash Price |
$100.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$94.03
|
| Rate for Payer: Medical Associates Commercial |
$94.03
|
| Rate for Payer: Midlands Choice Commercial |
$87.76
|
| Rate for Payer: United Healthcare Commercial |
$112.83
|
|
|
nitroglycerin 2% Top Oint [VDMC]
|
Facility
|
IP
|
$16.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436514
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$14.50 |
| Rate for Payer: Aetna of IA Commercial |
$14.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.50
|
| Rate for Payer: Cash Price |
$12.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.08
|
| Rate for Payer: Medical Associates Commercial |
$12.08
|
| Rate for Payer: Midlands Choice Commercial |
$11.28
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
|
|
nitroglycerin 2% Top Oint [VDMC]
|
Facility
|
OP
|
$16.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436514
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.25 |
| Max. Negotiated Rate |
$14.50 |
| Rate for Payer: Aetna of IA Commercial |
$14.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.50
|
| Rate for Payer: Aetna of IA Medicare |
$9.18
|
| Rate for Payer: Amerigroup Medicaid |
$9.29
|
| Rate for Payer: Amerigroup Medicare |
$7.32
|
| Rate for Payer: Cash Price |
$12.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.20
|
| Rate for Payer: Medical Associates Commercial |
$12.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.25
|
| Rate for Payer: Midlands Choice Commercial |
$11.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.34
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.50
|
|
|
NM Bone Imaging Limited
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
CPT 78300
|
| Hospital Charge Code |
1169176
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$822.50 |
| Max. Negotiated Rate |
$1,057.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,057.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,057.50
|
| Rate for Payer: Cash Price |
$940.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$881.25
|
| Rate for Payer: Medical Associates Commercial |
$881.25
|
| Rate for Payer: Midlands Choice Commercial |
$822.50
|
| Rate for Payer: United Healthcare Commercial |
$1,057.50
|
|
|
NM Bone Imaging Limited
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
CPT 78300
|
| Hospital Charge Code |
1169176
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$528.75 |
| Max. Negotiated Rate |
$1,057.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,057.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,057.50
|
| Rate for Payer: Aetna of IA Medicare |
$669.75
|
| Rate for Payer: Amerigroup Medicaid |
$677.74
|
| Rate for Payer: Amerigroup Medicare |
$534.04
|
| Rate for Payer: Cash Price |
$940.00
|
| Rate for Payer: Cash Price |
$940.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$881.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$528.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$671.16
|
| Rate for Payer: Medical Associates Commercial |
$881.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$528.75
|
| Rate for Payer: Midlands Choice Commercial |
$822.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$681.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$608.06
|
| Rate for Payer: United Healthcare Commercial |
$1,057.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$693.25
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Bone Imaging Whole Body
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78306
|
| Hospital Charge Code |
1169180
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
