|
AMNION THIN GRAFT 4CMX6CM
|
Facility
|
IP
|
$5,445.00
|
|
|
Service Code
|
CPT A4649
|
| Hospital Charge Code |
8782686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,811.50 |
| Max. Negotiated Rate |
$4,900.50 |
| Rate for Payer: Aetna of IA Commercial |
$4,900.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,900.50
|
| Rate for Payer: Cash Price |
$4,356.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,083.75
|
| Rate for Payer: Medical Associates Commercial |
$4,083.75
|
| Rate for Payer: Midlands Choice Commercial |
$3,811.50
|
| Rate for Payer: United Healthcare Commercial |
$4,900.50
|
|
|
AMNION THIN GRAFT 4CMX6CM
|
Facility
|
OP
|
$5,445.00
|
|
|
Service Code
|
CPT A4649
|
| Hospital Charge Code |
8782686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,721.41 |
| Max. Negotiated Rate |
$4,900.50 |
| Rate for Payer: Aetna of IA Commercial |
$4,900.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,900.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,103.65
|
| Rate for Payer: Amerigroup Medicaid |
$2,748.09
|
| Rate for Payer: Amerigroup Medicare |
$2,749.72
|
| Rate for Payer: Cash Price |
$4,356.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,083.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,722.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,721.41
|
| Rate for Payer: Medical Associates Commercial |
$4,083.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,722.50
|
| Rate for Payer: Midlands Choice Commercial |
$3,811.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,763.34
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$2,761.70
|
| Rate for Payer: Oscar Health of IA Commercial |
$4,083.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,083.75
|
| Rate for Payer: United Healthcare Commercial |
$4,900.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,212.55
|
|
|
amoxicillin 200 mg/5 mL 50ml suspension[VDMC]
|
Facility
|
OP
|
$12.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
13890415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Aetna of IA Commercial |
$11.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.30
|
| Rate for Payer: Aetna of IA Medicare |
$7.16
|
| Rate for Payer: Amerigroup Medicaid |
$6.34
|
| Rate for Payer: Amerigroup Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.28
|
| Rate for Payer: Medical Associates Commercial |
$9.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.28
|
| Rate for Payer: Midlands Choice Commercial |
$8.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.37
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$6.37
|
| Rate for Payer: Oscar Health of IA Commercial |
$9.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.42
|
| Rate for Payer: United Healthcare Commercial |
$11.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.41
|
|
|
amoxicillin 200 mg/5 mL 50ml suspension[VDMC]
|
Facility
|
IP
|
$12.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
13890415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.79 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Aetna of IA Commercial |
$11.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.30
|
| Rate for Payer: Cash Price |
$10.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.42
|
| Rate for Payer: Medical Associates Commercial |
$9.42
|
| Rate for Payer: Midlands Choice Commercial |
$8.79
|
| Rate for Payer: United Healthcare Commercial |
$11.30
|
|
|
amoxicillin 400 mg/5 mL 50 ml Pow [VDMC]
|
Facility
|
OP
|
$17.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
13887550
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$15.77 |
| Rate for Payer: Aetna of IA Commercial |
$15.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.77
|
| Rate for Payer: Aetna of IA Medicare |
$9.99
|
| Rate for Payer: Amerigroup Medicaid |
$8.84
|
| Rate for Payer: Amerigroup Medicare |
$8.85
|
| Rate for Payer: Cash Price |
$14.02
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.76
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.76
|
| Rate for Payer: Medical Associates Commercial |
$13.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.76
|
| Rate for Payer: Midlands Choice Commercial |
$12.26
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.89
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$8.89
|
| Rate for Payer: Oscar Health of IA Commercial |
$13.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.14
|
| Rate for Payer: United Healthcare Commercial |
$15.77
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.34
|
|
|
amoxicillin 400 mg/5 mL 50 ml Pow [VDMC]
|
Facility
|
IP
|
$17.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
13887550
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.26 |
| Max. Negotiated Rate |
$15.77 |
| Rate for Payer: Aetna of IA Commercial |
$15.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.77
|
| Rate for Payer: Cash Price |
$14.02
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.14
|
| Rate for Payer: Medical Associates Commercial |
$13.14
|
| Rate for Payer: Midlands Choice Commercial |
$12.26
|
| Rate for Payer: United Healthcare Commercial |
$15.77
|
|
|
amoxicillin 500 mg Cap [VDMC]
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10431311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of IA Commercial |
$1.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.39
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.16
|
| Rate for Payer: Medical Associates Commercial |
$1.16
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
|
|
amoxicillin 500 mg Cap [VDMC]
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10431311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of IA Commercial |
$1.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.39
|
| Rate for Payer: Aetna of IA Medicare |
$0.88
|
| Rate for Payer: Amerigroup Medicaid |
$0.78
|
| Rate for Payer: Amerigroup Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.77
|
| Rate for Payer: Medical Associates Commercial |
$1.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.77
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.78
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.78
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.91
|
|
|
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL 75 ML Pow[VDMC]
|
Facility
|
OP
|
$177.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14016315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$88.62 |
| Max. Negotiated Rate |
$159.59 |
| Rate for Payer: Aetna of IA Commercial |
$159.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$159.59
|
| Rate for Payer: Aetna of IA Medicare |
$101.07
|
| Rate for Payer: Amerigroup Medicaid |
$89.49
|
| Rate for Payer: Amerigroup Medicare |
$89.55
|
| Rate for Payer: Cash Price |
$141.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.99
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$88.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$88.62
|
| Rate for Payer: Medical Associates Commercial |
$132.99
|
| Rate for Payer: Medical Associates Managed Medicare |
$88.66
|
| Rate for Payer: Midlands Choice Commercial |
$124.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$89.99
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$89.94
|
| Rate for Payer: Oscar Health of IA Commercial |
$132.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$132.99
|
| Rate for Payer: United Healthcare Commercial |
$159.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$104.62
|
|
|
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL 75 ML Pow[VDMC]
|
Facility
|
IP
|
$177.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14016315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$124.12 |
| Max. Negotiated Rate |
$159.59 |
| Rate for Payer: Aetna of IA Commercial |
$159.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$159.59
|
| Rate for Payer: Cash Price |
$141.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.99
|
| Rate for Payer: Medical Associates Commercial |
$132.99
|
| Rate for Payer: Midlands Choice Commercial |
$124.12
|
| Rate for Payer: United Healthcare Commercial |
$159.59
|
|
|
amoxicillin-clavulanate 500 mg-125 mg Tab [VDMC]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366660
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of IA Commercial |
$1.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.73
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.44
|
| Rate for Payer: Medical Associates Commercial |
$1.44
|
| Rate for Payer: Midlands Choice Commercial |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.73
|
|
|
amoxicillin-clavulanate 500 mg-125 mg Tab [VDMC]
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366660
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of IA Commercial |
$1.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.73
|
| Rate for Payer: Aetna of IA Medicare |
$1.09
|
| Rate for Payer: Amerigroup Medicaid |
$0.97
|
| Rate for Payer: Amerigroup Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.96
|
| Rate for Payer: Medical Associates Commercial |
$1.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.96
|
| Rate for Payer: Midlands Choice Commercial |
$1.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.97
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.97
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.44
|
| Rate for Payer: United Healthcare Commercial |
$1.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.13
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [VDMC]
|
Facility
|
OP
|
$2.73
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna of IA Commercial |
$2.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.46
|
| Rate for Payer: Aetna of IA Medicare |
$1.56
|
| Rate for Payer: Amerigroup Medicaid |
$1.38
|
| Rate for Payer: Amerigroup Medicare |
$1.38
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.05
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.36
|
| Rate for Payer: Medical Associates Commercial |
$2.05
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.36
|
| Rate for Payer: Midlands Choice Commercial |
$1.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.39
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.38
|
| Rate for Payer: Oscar Health of IA Commercial |
$2.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.05
|
| Rate for Payer: United Healthcare Commercial |
$2.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.61
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [VDMC]
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna of IA Commercial |
$2.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.46
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.05
|
| Rate for Payer: Medical Associates Commercial |
$2.05
|
| Rate for Payer: Midlands Choice Commercial |
$1.91
|
| Rate for Payer: United Healthcare Commercial |
$2.46
|
|
|
amphotericin B 50 mg soln SDV [VDMC]
|
Facility
|
IP
|
$152.76
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
10432598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$106.93 |
| Max. Negotiated Rate |
$137.48 |
| Rate for Payer: Aetna of IA Commercial |
$137.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$137.48
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.57
|
| Rate for Payer: Medical Associates Commercial |
$114.57
|
| Rate for Payer: Midlands Choice Commercial |
$106.93
|
| Rate for Payer: United Healthcare Commercial |
$137.48
|
|
|
amphotericin B 50 mg soln SDV [VDMC]
|
Facility
|
OP
|
$152.76
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
10432598
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$76.35 |
| Max. Negotiated Rate |
$137.48 |
| Rate for Payer: Aetna of IA Commercial |
$137.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$137.48
|
| Rate for Payer: Aetna of IA Medicare |
$87.07
|
| Rate for Payer: Amerigroup Medicaid |
$77.10
|
| Rate for Payer: Amerigroup Medicare |
$77.14
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.57
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$76.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$76.35
|
| Rate for Payer: Medical Associates Commercial |
$114.57
|
| Rate for Payer: Medical Associates Managed Medicare |
$76.38
|
| Rate for Payer: Midlands Choice Commercial |
$106.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$77.53
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$77.48
|
| Rate for Payer: Oscar Health of IA Commercial |
$114.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$114.57
|
| Rate for Payer: United Healthcare Commercial |
$137.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$90.13
|
|
|
amphotericin B liposomal 50 mg IV Inj SDV [VDMC]
|
Facility
|
OP
|
$289.84
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
10366798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$144.86 |
| Max. Negotiated Rate |
$260.86 |
| Rate for Payer: Aetna of IA Commercial |
$260.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$260.86
|
| Rate for Payer: Aetna of IA Medicare |
$165.21
|
| Rate for Payer: Amerigroup Medicaid |
$146.28
|
| Rate for Payer: Amerigroup Medicare |
$146.37
|
| Rate for Payer: Cash Price |
$231.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$217.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$144.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$144.86
|
| Rate for Payer: Medical Associates Commercial |
$217.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$144.92
|
| Rate for Payer: Midlands Choice Commercial |
$202.89
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$147.09
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$147.01
|
| Rate for Payer: Oscar Health of IA Commercial |
$217.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$217.38
|
| Rate for Payer: United Healthcare Commercial |
$260.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$171.01
|
|
|
amphotericin B liposomal 50 mg IV Inj SDV [VDMC]
|
Facility
|
IP
|
$289.84
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
10366798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$202.89 |
| Max. Negotiated Rate |
$260.86 |
| Rate for Payer: Aetna of IA Commercial |
$260.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$260.86
|
| Rate for Payer: Cash Price |
$231.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$217.38
|
| Rate for Payer: Medical Associates Commercial |
$217.38
|
| Rate for Payer: Midlands Choice Commercial |
$202.89
|
| Rate for Payer: United Healthcare Commercial |
$260.86
|
|
|
ampicillin 1 g Inj SDV [VDMC]
|
Facility
|
OP
|
$24.81
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10366865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$22.33 |
| Rate for Payer: Aetna of IA Commercial |
$22.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.33
|
| Rate for Payer: Aetna of IA Medicare |
$14.14
|
| Rate for Payer: Amerigroup Medicaid |
$12.52
|
| Rate for Payer: Amerigroup Medicare |
$12.53
|
| Rate for Payer: Cash Price |
$19.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.61
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.40
|
| Rate for Payer: Medical Associates Commercial |
$18.61
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.40
|
| Rate for Payer: Midlands Choice Commercial |
$17.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.59
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.58
|
| Rate for Payer: Oscar Health of IA Commercial |
$18.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.61
|
| Rate for Payer: United Healthcare Commercial |
$22.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.64
|
|
|
ampicillin 1 g Inj SDV [VDMC]
|
Facility
|
IP
|
$24.81
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10366865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.37 |
| Max. Negotiated Rate |
$22.33 |
| Rate for Payer: Aetna of IA Commercial |
$22.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.33
|
| Rate for Payer: Cash Price |
$19.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.61
|
| Rate for Payer: Medical Associates Commercial |
$18.61
|
| Rate for Payer: Midlands Choice Commercial |
$17.37
|
| Rate for Payer: United Healthcare Commercial |
$22.33
|
|
|
ampicillin 2 g Inj SDV [VDMC]
|
Facility
|
OP
|
$28.08
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10367003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.03 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Aetna of IA Commercial |
$25.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.27
|
| Rate for Payer: Aetna of IA Medicare |
$16.01
|
| Rate for Payer: Amerigroup Medicaid |
$14.17
|
| Rate for Payer: Amerigroup Medicare |
$14.18
|
| Rate for Payer: Cash Price |
$22.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.03
|
| Rate for Payer: Medical Associates Commercial |
$21.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.04
|
| Rate for Payer: Midlands Choice Commercial |
$19.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$14.24
|
| Rate for Payer: Oscar Health of IA Commercial |
$21.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.06
|
| Rate for Payer: United Healthcare Commercial |
$25.27
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.57
|
|
|
ampicillin 2 g Inj SDV [VDMC]
|
Facility
|
IP
|
$28.08
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10367003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Aetna of IA Commercial |
$25.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.27
|
| Rate for Payer: Cash Price |
$22.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.06
|
| Rate for Payer: Medical Associates Commercial |
$21.06
|
| Rate for Payer: Midlands Choice Commercial |
$19.66
|
| Rate for Payer: United Healthcare Commercial |
$25.27
|
|
|
ampicillin 500 mg Inj SDV [VDMC]
|
Facility
|
OP
|
$23.32
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10367072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$20.99 |
| Rate for Payer: Aetna of IA Commercial |
$20.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.99
|
| Rate for Payer: Aetna of IA Medicare |
$13.29
|
| Rate for Payer: Amerigroup Medicaid |
$11.77
|
| Rate for Payer: Amerigroup Medicare |
$11.78
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.49
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.66
|
| Rate for Payer: Medical Associates Commercial |
$17.49
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.66
|
| Rate for Payer: Midlands Choice Commercial |
$16.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.83
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$11.83
|
| Rate for Payer: Oscar Health of IA Commercial |
$17.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.49
|
| Rate for Payer: United Healthcare Commercial |
$20.99
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.76
|
|
|
ampicillin 500 mg Inj SDV [VDMC]
|
Facility
|
IP
|
$23.32
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10367072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$20.99 |
| Rate for Payer: Aetna of IA Commercial |
$20.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.99
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.49
|
| Rate for Payer: Medical Associates Commercial |
$17.49
|
| Rate for Payer: Midlands Choice Commercial |
$16.32
|
| Rate for Payer: United Healthcare Commercial |
$20.99
|
|
|
ampicillin-sulbactam 1.5 GM Inj SDV [VDMC]
|
Facility
|
OP
|
$25.04
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
10367141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$22.54 |
| Rate for Payer: Aetna of IA Commercial |
$22.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.54
|
| Rate for Payer: Aetna of IA Medicare |
$14.27
|
| Rate for Payer: Amerigroup Medicaid |
$12.64
|
| Rate for Payer: Amerigroup Medicare |
$12.65
|
| Rate for Payer: Cash Price |
$20.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.51
|
| Rate for Payer: Medical Associates Commercial |
$18.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.52
|
| Rate for Payer: Midlands Choice Commercial |
$17.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.71
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.70
|
| Rate for Payer: Oscar Health of IA Commercial |
$18.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.78
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.77
|
|
