|
REV OR REM IMPL SPINAL NS PG OR RECEIVER
|
Professional
|
Both
|
$1,249.00
|
|
|
Service Code
|
CPT 63688
|
| Hospital Charge Code |
8015878
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$369.25 |
| Max. Negotiated Rate |
$936.75 |
| Rate for Payer: Amerigroup Medicaid |
$372.87
|
| Rate for Payer: Cash Price |
$999.20
|
| Rate for Payer: Cash Price |
$999.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$369.25
|
| Rate for Payer: Medical Associates Commercial |
$936.75
|
| Rate for Payer: Midlands Choice Commercial |
$874.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$371.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$936.75
|
| Rate for Payer: United Healthcare Commercial |
$557.62
|
| Rate for Payer: Wellmark IA HMO WHPI |
$569.40
|
| Rate for Payer: Wellmark IA PPO |
$669.90
|
|
|
Rheumatoid Factor DMCL
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 86431
|
| Hospital Charge Code |
8037797
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
|
|
Rheumatoid Factor DMCL
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
CPT 86431
|
| Hospital Charge Code |
8037797
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Aetna of IA Medicare |
$33.06
|
| Rate for Payer: Amerigroup Medicaid |
$33.45
|
| Rate for Payer: Amerigroup Medicare |
$26.36
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.13
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.10
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.02
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.22
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
RHIG
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
CPT 90384
|
| Hospital Charge Code |
1378504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.10 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of IA Commercial |
$119.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$119.70
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$99.75
|
| Rate for Payer: Medical Associates Commercial |
$99.75
|
| Rate for Payer: Midlands Choice Commercial |
$93.10
|
| Rate for Payer: United Healthcare Commercial |
$119.70
|
|
|
RHIG
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
CPT 90384
|
| Hospital Charge Code |
1378504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.85 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of IA Commercial |
$119.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$119.70
|
| Rate for Payer: Aetna of IA Medicare |
$75.81
|
| Rate for Payer: Amerigroup Medicaid |
$76.71
|
| Rate for Payer: Amerigroup Medicare |
$60.45
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$99.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$59.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$75.97
|
| Rate for Payer: Medical Associates Commercial |
$99.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.85
|
| Rate for Payer: Midlands Choice Commercial |
$93.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$77.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$68.83
|
| Rate for Payer: United Healthcare Commercial |
$119.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$78.47
|
|
|
RH TYPING
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
8015194
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$55.45 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Aetna of IA Medicare |
$29.64
|
| Rate for Payer: Amerigroup Medicaid |
$29.99
|
| Rate for Payer: Amerigroup Medicare |
$23.63
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$29.70
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.40
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.91
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.68
|
| Rate for Payer: Wellmark IA HMO WHPI |
$50.34
|
| Rate for Payer: Wellmark IA PPO |
$55.45
|
|
|
RH TYPING
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
8015194
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
|
|
Rhythm Strip
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 93041
|
| Hospital Charge Code |
7068798
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Aetna of IA Medicare |
$59.28
|
| Rate for Payer: Amerigroup Medicaid |
$59.99
|
| Rate for Payer: Amerigroup Medicare |
$47.27
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$46.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.40
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$46.80
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$53.82
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.36
|
| Rate for Payer: Wellmark IA HMO WHPI |
$75.15
|
| Rate for Payer: Wellmark IA PPO |
$82.79
|
|
|
Rhythm Strip
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 93041
|
| Hospital Charge Code |
7068798
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
|
|
riboflavin 100 mg Tab [VDMC]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10418882
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Aetna of IA Medicare |
$0.69
|
| Rate for Payer: Amerigroup Medicaid |
$0.70
|
| Rate for Payer: Amerigroup Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.91
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.70
|
| Rate for Payer: Medical Associates Commercial |
$0.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.55
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.72
|
|
|
riboflavin 100 mg Tab [VDMC]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10418882
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.91
|
| Rate for Payer: Medical Associates Commercial |
$0.91
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
|
|
rifampin 300mg cap [VDMC]
|
Facility
|
IP
|
$3.39
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419087
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna of IA Commercial |
$3.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.05
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.54
|
| Rate for Payer: Medical Associates Commercial |
$2.54
|
| Rate for Payer: Midlands Choice Commercial |
$2.37
|
| Rate for Payer: United Healthcare Commercial |
$3.05
|
|
|
rifampin 300mg cap [VDMC]
|
Facility
|
OP
|
$3.39
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419087
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna of IA Commercial |
$3.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.05
|
| Rate for Payer: Aetna of IA Medicare |
$1.93
|
| Rate for Payer: Amerigroup Medicaid |
$1.96
|
| Rate for Payer: Amerigroup Medicare |
$1.54
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.53
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.94
|
| Rate for Payer: Medical Associates Commercial |
$2.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.53
|
| Rate for Payer: Midlands Choice Commercial |
$2.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$3.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.00
|
|
|
rifampin 600 mg IV Inj [VDMC]
|
Facility
|
IP
|
$236.56
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10418951
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$165.59 |
| Max. Negotiated Rate |
$212.90 |
| Rate for Payer: Aetna of IA Commercial |
$212.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$212.90
|
| Rate for Payer: Cash Price |
$189.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$177.42
|
| Rate for Payer: Medical Associates Commercial |
$177.42
|
| Rate for Payer: Midlands Choice Commercial |
$165.59
|
| Rate for Payer: United Healthcare Commercial |
$212.90
|
|
|
rifampin 600 mg IV Inj [VDMC]
|
Facility
|
OP
|
$236.56
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10418951
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$106.45 |
| Max. Negotiated Rate |
$212.90 |
| Rate for Payer: Aetna of IA Commercial |
$212.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$212.90
|
| Rate for Payer: Aetna of IA Medicare |
$134.84
|
| Rate for Payer: Amerigroup Medicaid |
$136.45
|
| Rate for Payer: Amerigroup Medicare |
$107.52
|
| Rate for Payer: Cash Price |
$189.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$177.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$106.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$135.12
|
| Rate for Payer: Medical Associates Commercial |
$177.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$106.45
|
| Rate for Payer: Midlands Choice Commercial |
$165.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$122.42
|
| Rate for Payer: United Healthcare Commercial |
$212.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$139.57
|
|
|
RING CAPSULAR TENSION 12MM
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047043
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna of IA Commercial |
$115.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$115.20
|
| Rate for Payer: Aetna of IA Medicare |
$72.96
|
| Rate for Payer: Amerigroup Medicaid |
$73.83
|
| Rate for Payer: Amerigroup Medicare |
$58.18
|
| Rate for Payer: Cash Price |
$102.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.11
|
| Rate for Payer: Medical Associates Commercial |
$96.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.60
|
| Rate for Payer: Midlands Choice Commercial |
$89.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$66.24
|
| Rate for Payer: United Healthcare Commercial |
$115.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$75.52
|
|
|
RING CAPSULAR TENSION 12MM
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047043
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$89.60 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna of IA Commercial |
$115.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$115.20
|
| Rate for Payer: Cash Price |
$102.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.00
|
| Rate for Payer: Medical Associates Commercial |
$96.00
|
| Rate for Payer: Midlands Choice Commercial |
$89.60
|
| Rate for Payer: United Healthcare Commercial |
$115.20
|
|
|
RING, CAPSULAR, TENSION TYPE 14
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
8988548
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$277.20 |
| Max. Negotiated Rate |
$356.40 |
| Rate for Payer: Aetna of IA Commercial |
$356.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$356.40
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$297.00
|
| Rate for Payer: Medical Associates Commercial |
$297.00
|
| Rate for Payer: Midlands Choice Commercial |
$277.20
|
| Rate for Payer: United Healthcare Commercial |
$356.40
|
|
|
RING, CAPSULAR, TENSION TYPE 14
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
8988548
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$356.40 |
| Rate for Payer: Aetna of IA Commercial |
$356.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$356.40
|
| Rate for Payer: Aetna of IA Medicare |
$225.72
|
| Rate for Payer: Amerigroup Medicaid |
$228.41
|
| Rate for Payer: Amerigroup Medicare |
$179.98
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$297.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$178.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$226.20
|
| Rate for Payer: Medical Associates Commercial |
$297.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$178.20
|
| Rate for Payer: Midlands Choice Commercial |
$277.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$229.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$204.93
|
| Rate for Payer: United Healthcare Commercial |
$356.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$233.64
|
|
|
risperiDONE 0.25 mg Tab [VDMC]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.07
|
| Rate for Payer: Medical Associates Commercial |
$1.07
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
|
|
risperiDONE 0.25 mg Tab [VDMC]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Aetna of IA Medicare |
$0.81
|
| Rate for Payer: Amerigroup Medicaid |
$0.82
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.82
|
| Rate for Payer: Medical Associates Commercial |
$1.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.64
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.84
|
|
|
risperiDONE 1 mg Tab [VDMC]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419292
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.07
|
| Rate for Payer: Medical Associates Commercial |
$1.07
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
|
|
risperiDONE 1 mg Tab [VDMC]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10419292
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.83
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.82
|
| Rate for Payer: Medical Associates Commercial |
$1.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.64
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
|
riTUXimab-abbs 10mg/mL 50mL SDV [VDMC]
|
Facility
|
IP
|
$4,914.14
|
|
|
Service Code
|
HCPCS Q5115
|
| Hospital Charge Code |
25843432
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3,439.90 |
| Max. Negotiated Rate |
$4,422.73 |
| Rate for Payer: Aetna of IA Commercial |
$4,422.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,422.73
|
| Rate for Payer: Cash Price |
$3,931.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,685.60
|
| Rate for Payer: Medical Associates Commercial |
$3,685.60
|
| Rate for Payer: Midlands Choice Commercial |
$3,439.90
|
| Rate for Payer: United Healthcare Commercial |
$4,422.73
|
|
|
riTUXimab-abbs 10mg/mL 50mL SDV [VDMC]
|
Facility
|
OP
|
$4,914.14
|
|
|
Service Code
|
HCPCS Q5115
|
| Hospital Charge Code |
25843432
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,211.36 |
| Max. Negotiated Rate |
$4,422.73 |
| Rate for Payer: Aetna of IA Commercial |
$4,422.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,422.73
|
| Rate for Payer: Aetna of IA Medicare |
$2,801.06
|
| Rate for Payer: Amerigroup Medicaid |
$2,834.48
|
| Rate for Payer: Amerigroup Medicare |
$2,233.48
|
| Rate for Payer: Cash Price |
$3,931.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,685.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,211.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,806.96
|
| Rate for Payer: Medical Associates Commercial |
$3,685.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,211.36
|
| Rate for Payer: Midlands Choice Commercial |
$3,439.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,848.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,543.07
|
| Rate for Payer: United Healthcare Commercial |
$4,422.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,899.34
|
|
