|
pyridostiGMine 5 mg/mL Inj Sol [VDMC]
|
Facility
|
IP
|
$140.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10417699
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$98.43 |
| Max. Negotiated Rate |
$126.56 |
| Rate for Payer: Aetna of IA Commercial |
$126.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.56
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.46
|
| Rate for Payer: Medical Associates Commercial |
$105.46
|
| Rate for Payer: Midlands Choice Commercial |
$98.43
|
| Rate for Payer: United Healthcare Commercial |
$126.56
|
|
|
pyridostiGMine 5 mg/mL Inj Sol [VDMC]
|
Facility
|
OP
|
$140.62
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10417699
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.28 |
| Max. Negotiated Rate |
$126.56 |
| Rate for Payer: Aetna of IA Commercial |
$126.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.56
|
| Rate for Payer: Aetna of IA Medicare |
$80.15
|
| Rate for Payer: Amerigroup Medicaid |
$81.11
|
| Rate for Payer: Amerigroup Medicare |
$63.91
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.46
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$63.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$80.32
|
| Rate for Payer: Medical Associates Commercial |
$105.46
|
| Rate for Payer: Medical Associates Managed Medicare |
$63.28
|
| Rate for Payer: Midlands Choice Commercial |
$98.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$81.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$72.77
|
| Rate for Payer: United Healthcare Commercial |
$126.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.97
|
|
|
pyridostiGMine 60 mg Tab [VDMC]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417770
|
|
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
|
|
|
pyridostiGMine 60 mg Tab [VDMC]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417770
|
|
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
|
|
|
pyridoxine 100 mg/mL 1ml MDV Inj [VDMC]
|
Facility
|
IP
|
$51.24
|
|
|
Service Code
|
HCPCS J3415
|
| Hospital Charge Code |
10417841
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.87 |
| Max. Negotiated Rate |
$46.11 |
| Rate for Payer: Aetna of IA Commercial |
$46.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.11
|
| Rate for Payer: Cash Price |
$40.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.43
|
| Rate for Payer: Medical Associates Commercial |
$38.43
|
| Rate for Payer: Midlands Choice Commercial |
$35.87
|
| Rate for Payer: United Healthcare Commercial |
$46.11
|
|
|
pyridoxine 100 mg/mL 1ml MDV Inj [VDMC]
|
Facility
|
OP
|
$51.24
|
|
|
Service Code
|
HCPCS J3415
|
| Hospital Charge Code |
10417841
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.06 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$46.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.11
|
| Rate for Payer: Aetna of IA Medicare |
$29.20
|
| Rate for Payer: Amerigroup Medicaid |
$29.55
|
| Rate for Payer: Amerigroup Medicare |
$23.29
|
| Rate for Payer: Cash Price |
$40.99
|
| Rate for Payer: Cash Price |
$40.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$29.27
|
| Rate for Payer: Medical Associates Commercial |
$38.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.06
|
| Rate for Payer: Midlands Choice Commercial |
$35.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.52
|
| Rate for Payer: United Healthcare Commercial |
$46.11
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.23
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
pyridoxine 50 mg Tab [VDMC]
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417910
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of IA Commercial |
$0.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.94
|
| Rate for Payer: Aetna of IA Medicare |
$0.60
|
| Rate for Payer: Amerigroup Medicaid |
$0.60
|
| Rate for Payer: Amerigroup Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.79
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.60
|
| Rate for Payer: Medical Associates Commercial |
$0.79
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.47
|
| Rate for Payer: Midlands Choice Commercial |
$0.73
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.54
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.62
|
|
|
pyridoxine 50 mg Tab [VDMC]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417910
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of IA Commercial |
$0.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.94
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.79
|
| Rate for Payer: Medical Associates Commercial |
$0.79
|
| Rate for Payer: Midlands Choice Commercial |
$0.73
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
|
|
Quantiferon TB Gold Plus DMCL
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 86480
|
| Hospital Charge Code |
8488909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna of IA Commercial |
$126.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.00
|
| Rate for Payer: Medical Associates Commercial |
$105.00
|
| Rate for Payer: Midlands Choice Commercial |
$98.00
|
| Rate for Payer: United Healthcare Commercial |
$126.00
|
|
|
Quantiferon TB Gold Plus DMCL
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 86480
|
| Hospital Charge Code |
8488909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna of IA Commercial |
$126.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.00
|
| Rate for Payer: Aetna of IA Medicare |
$79.80
|
| Rate for Payer: Amerigroup Medicaid |
$80.75
|
| Rate for Payer: Amerigroup Medicare |
$63.63
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$63.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$79.97
|
| Rate for Payer: Medical Associates Commercial |
$105.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$63.00
|
| Rate for Payer: Midlands Choice Commercial |
$98.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$81.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$72.45
|
| Rate for Payer: United Healthcare Commercial |
$126.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.60
|
| Rate for Payer: Wellmark IA HMO WHPI |
$104.22
|
| Rate for Payer: Wellmark IA PPO |
$114.81
|
|
|
QUEtiapine 100 mg Tab [VDMC]
|
Facility
|
OP
|
$1.59
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of IA Commercial |
$1.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.43
|
| Rate for Payer: Aetna of IA Medicare |
$0.91
|
| Rate for Payer: Amerigroup Medicaid |
$0.92
|
| Rate for Payer: Amerigroup Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.91
|
| Rate for Payer: Medical Associates Commercial |
$1.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.72
|
| Rate for Payer: Midlands Choice Commercial |
$1.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.94
|
|
|
QUEtiapine 100 mg Tab [VDMC]
|
Facility
|
IP
|
$1.59
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10417979
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of IA Commercial |
$1.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.43
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.19
|
| Rate for Payer: Medical Associates Commercial |
$1.19
|
| Rate for Payer: Midlands Choice Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
|
|
QUEtiapine 25 mg Tab [VDMC]
|
Facility
|
IP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10418050
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
|
|
QUEtiapine 25 mg Tab [VDMC]
|
Facility
|
OP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10418050
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.83
|
| Rate for Payer: Amerigroup Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.83
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.65
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.75
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
|
QUICKFIX SCREW 2X10MM
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8852325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$194.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Aetna of IA Medicare |
$246.24
|
| Rate for Payer: Amerigroup Medicaid |
$249.18
|
| Rate for Payer: Amerigroup Medicare |
$196.34
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$194.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$246.76
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$194.40
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$250.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$223.56
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$254.88
|
|
|
QUICKFIX SCREW 2X10MM
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8852325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$302.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
|
|
QUICKFIX SCREW 2X11MM
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
8463228
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$302.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
|
|
QUICKFIX SCREW 2X11MM
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
8463228
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$194.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Aetna of IA Medicare |
$246.24
|
| Rate for Payer: Amerigroup Medicaid |
$249.18
|
| Rate for Payer: Amerigroup Medicare |
$196.34
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$194.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$246.76
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$194.40
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$250.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$223.56
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$254.88
|
|
|
QUICKFIX SCREW 2X13MM
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8852327
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$194.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Aetna of IA Medicare |
$246.24
|
| Rate for Payer: Amerigroup Medicaid |
$249.18
|
| Rate for Payer: Amerigroup Medicare |
$196.34
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$194.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$246.76
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$194.40
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$250.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$223.56
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$254.88
|
|
|
QUICKFIX SCREW 2X13MM
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8852327
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$302.40 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of IA Commercial |
$388.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$388.80
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$324.00
|
| Rate for Payer: Medical Associates Commercial |
$324.00
|
| Rate for Payer: Midlands Choice Commercial |
$302.40
|
| Rate for Payer: United Healthcare Commercial |
$388.80
|
|
|
Qutenza Administration Charge
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
CPT 17999
|
| Hospital Charge Code |
8964103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$333.49 |
| Rate for Payer: Aetna of IA Commercial |
$270.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$270.00
|
| Rate for Payer: Aetna of IA Medicare |
$171.00
|
| Rate for Payer: Amerigroup Medicaid |
$173.04
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$225.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$171.36
|
| Rate for Payer: Medical Associates Commercial |
$225.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$210.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$173.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$155.25
|
| Rate for Payer: United Healthcare Commercial |
$270.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$177.00
|
| Rate for Payer: Wellmark IA HMO WHPI |
$302.74
|
| Rate for Payer: Wellmark IA PPO |
$333.49
|
|
|
Qutenza Administration Charge
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
CPT 17999
|
| Hospital Charge Code |
8964103
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna of IA Commercial |
$270.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$270.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$225.00
|
| Rate for Payer: Medical Associates Commercial |
$225.00
|
| Rate for Payer: Midlands Choice Commercial |
$210.00
|
| Rate for Payer: United Healthcare Commercial |
$270.00
|
|
|
rabies immune globulin, human 150 intl units/mL 2ml IM SDV [VDMC]
|
Facility
|
OP
|
$1,775.00
|
|
|
Service Code
|
HCPCS 90376
|
| Hospital Charge Code |
10432228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$798.75 |
| Max. Negotiated Rate |
$1,597.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,597.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,597.50
|
| Rate for Payer: Aetna of IA Medicare |
$1,011.75
|
| Rate for Payer: Amerigroup Medicaid |
$1,023.82
|
| Rate for Payer: Amerigroup Medicare |
$806.74
|
| Rate for Payer: Cash Price |
$1,420.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,331.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$798.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,013.88
|
| Rate for Payer: Medical Associates Commercial |
$1,331.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$798.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,242.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,028.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$918.56
|
| Rate for Payer: United Healthcare Commercial |
$1,597.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,047.25
|
|
|
rabies immune globulin, human 150 intl units/mL 2ml IM SDV [VDMC]
|
Facility
|
IP
|
$1,775.00
|
|
|
Service Code
|
HCPCS 90376
|
| Hospital Charge Code |
10432228
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,242.50 |
| Max. Negotiated Rate |
$1,597.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,597.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,597.50
|
| Rate for Payer: Cash Price |
$1,420.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,331.25
|
| Rate for Payer: Medical Associates Commercial |
$1,331.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,242.50
|
| Rate for Payer: United Healthcare Commercial |
$1,597.50
|
|
|
rabies vaccine, purified chick embryo cell 2.5 intl units SDV Pow[VDMC]
|
Facility
|
OP
|
$1,542.88
|
|
|
Service Code
|
HCPCS 90675
|
| Hospital Charge Code |
18398617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$363.72 |
| Max. Negotiated Rate |
$1,388.59 |
| Rate for Payer: Aetna of IA Commercial |
$1,388.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,388.59
|
| Rate for Payer: Aetna of IA Medicare |
$879.44
|
| Rate for Payer: Amerigroup Medicaid |
$889.93
|
| Rate for Payer: Amerigroup Medicare |
$701.24
|
| Rate for Payer: Cash Price |
$1,234.30
|
| Rate for Payer: Cash Price |
$1,234.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,157.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$694.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$881.29
|
| Rate for Payer: Medical Associates Commercial |
$1,157.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$694.30
|
| Rate for Payer: Midlands Choice Commercial |
$1,080.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$894.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$798.44
|
| Rate for Payer: United Healthcare Commercial |
$1,388.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$910.30
|
| Rate for Payer: Wellmark IA HMO WHPI |
$363.72
|
| Rate for Payer: Wellmark IA PPO |
$400.65
|
|
