|
TCOM/SPP - LIMITED 1-2 LEVELS
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
8013708
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna of IA Commercial |
$342.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.00
|
| Rate for Payer: Aetna of IA Medicare |
$216.60
|
| Rate for Payer: Amerigroup Medicaid |
$219.18
|
| Rate for Payer: Amerigroup Medicare |
$172.71
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$171.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$217.06
|
| Rate for Payer: Medical Associates Commercial |
$285.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$171.00
|
| Rate for Payer: Midlands Choice Commercial |
$266.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$220.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$196.65
|
| Rate for Payer: United Healthcare Commercial |
$342.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$224.20
|
|
|
TCOM/SPP - LIMITED 1-2 LEVELS
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 93922
|
| Hospital Charge Code |
8013708
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$266.00 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna of IA Commercial |
$342.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.00
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.00
|
| Rate for Payer: Medical Associates Commercial |
$285.00
|
| Rate for Payer: Midlands Choice Commercial |
$266.00
|
| Rate for Payer: United Healthcare Commercial |
$342.00
|
|
|
TELEHEALTH FACILITY FEE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
7855053
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$29.25 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Aetna of IA Medicare |
$37.05
|
| Rate for Payer: Amerigroup Medicaid |
$37.49
|
| Rate for Payer: Amerigroup Medicare |
$29.54
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.13
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.25
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.64
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.35
|
|
|
TELEHEALTH FACILITY FEE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
7855053
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of IA Commercial |
$58.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.50
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.75
|
| Rate for Payer: Medical Associates Commercial |
$48.75
|
| Rate for Payer: Midlands Choice Commercial |
$45.50
|
| Rate for Payer: United Healthcare Commercial |
$58.50
|
|
|
Telemetry
|
Facility
|
IP
|
$230.00
|
|
| Hospital Charge Code |
7466783
|
|
Hospital Revenue Code
|
110
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$2,580.60 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Aetna of IA Medicare |
$2,258.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,580.60
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,306.00
|
|
|
Telemetry Daily Charge
|
Facility
|
IP
|
$230.00
|
|
| Hospital Charge Code |
7863885
|
|
Hospital Revenue Code
|
110
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$2,580.60 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Aetna of IA Medicare |
$2,258.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,580.60
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,306.00
|
|
|
telmisartan 40 mg Tab [VDMC]
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10608819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna of IA Commercial |
$2.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.37
|
| Rate for Payer: Aetna of IA Medicare |
$1.50
|
| Rate for Payer: Amerigroup Medicaid |
$1.52
|
| Rate for Payer: Amerigroup Medicare |
$1.20
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.18
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.50
|
| Rate for Payer: Medical Associates Commercial |
$1.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.18
|
| Rate for Payer: Midlands Choice Commercial |
$1.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$2.37
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.55
|
|
|
telmisartan 40 mg Tab [VDMC]
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10608819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna of IA Commercial |
$2.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.37
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.97
|
| Rate for Payer: Medical Associates Commercial |
$1.97
|
| Rate for Payer: Midlands Choice Commercial |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$2.37
|
|
|
temazepam 15 mg Cap [VDMC]
|
Facility
|
OP
|
$3.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423701
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna of IA Commercial |
$2.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.86
|
| Rate for Payer: Aetna of IA Medicare |
$1.81
|
| Rate for Payer: Amerigroup Medicaid |
$1.83
|
| Rate for Payer: Amerigroup Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.81
|
| Rate for Payer: Medical Associates Commercial |
$2.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.43
|
| Rate for Payer: Midlands Choice Commercial |
$2.22
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.64
|
| Rate for Payer: United Healthcare Commercial |
$2.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.87
|
|
|
temazepam 15 mg Cap [VDMC]
|
Facility
|
IP
|
$3.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423701
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Aetna of IA Commercial |
$2.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.86
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.38
|
| Rate for Payer: Medical Associates Commercial |
$2.38
|
| Rate for Payer: Midlands Choice Commercial |
$2.22
|
| Rate for Payer: United Healthcare Commercial |
$2.86
|
|
|
TEMP EXTERNAL PACING
|
Professional
|
Both
|
$4.00
|
|
|
Service Code
|
CPT 92953
|
| Hospital Charge Code |
7982757
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Medical Associates Commercial |
$3.00
|
| Rate for Payer: Midlands Choice Commercial |
$2.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
|
|
TEMPORAL ARTERY PROCEDURE
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
CPT 37609
|
| Hospital Charge Code |
7982929
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$366.75 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Aetna of IA Medicare |
$464.55
|
| Rate for Payer: Amerigroup Medicaid |
$470.09
|
| Rate for Payer: Amerigroup Medicare |
$370.42
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$366.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$465.53
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$366.75
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$472.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$421.76
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$480.85
|
|
|
TEMPORAL ARTERY PROCEDURE
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
CPT 37609
|
| Hospital Charge Code |
7982929
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
|
|
TEMPORARY EXTERNAL PACING
|
Facility
|
OP
|
$505.00
|
|
|
Service Code
|
CPT 92953
|
| Hospital Charge Code |
4866866
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$227.25 |
| Max. Negotiated Rate |
$454.50 |
| Rate for Payer: Aetna of IA Commercial |
$454.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$454.50
|
| Rate for Payer: Aetna of IA Medicare |
$287.85
|
| Rate for Payer: Amerigroup Medicaid |
$291.28
|
| Rate for Payer: Amerigroup Medicare |
$229.52
|
| Rate for Payer: Cash Price |
$404.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$378.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$227.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$288.46
|
| Rate for Payer: Medical Associates Commercial |
$378.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$227.25
|
| Rate for Payer: Midlands Choice Commercial |
$353.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$292.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$261.34
|
| Rate for Payer: United Healthcare Commercial |
$454.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$297.95
|
|
|
TEMPORARY EXTERNAL PACING
|
Facility
|
IP
|
$505.00
|
|
|
Service Code
|
CPT 92953
|
| Hospital Charge Code |
4866866
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$353.50 |
| Max. Negotiated Rate |
$454.50 |
| Rate for Payer: Aetna of IA Commercial |
$454.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$454.50
|
| Rate for Payer: Cash Price |
$404.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$378.75
|
| Rate for Payer: Medical Associates Commercial |
$378.75
|
| Rate for Payer: Midlands Choice Commercial |
$353.50
|
| Rate for Payer: United Healthcare Commercial |
$454.50
|
|
|
TENDON GRACILIS
|
Facility
|
OP
|
$2,835.00
|
|
| Hospital Charge Code |
8047299
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.75 |
| Max. Negotiated Rate |
$2,551.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,551.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,551.50
|
| Rate for Payer: Aetna of IA Medicare |
$1,615.95
|
| Rate for Payer: Amerigroup Medicaid |
$1,635.23
|
| Rate for Payer: Amerigroup Medicare |
$1,288.51
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,126.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,275.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,619.35
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,275.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,643.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,467.11
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,672.65
|
|
|
TENDON GRACILIS
|
Facility
|
IP
|
$2,835.00
|
|
| Hospital Charge Code |
8047299
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,984.50 |
| Max. Negotiated Rate |
$2,551.50 |
| Rate for Payer: Aetna of IA Commercial |
$2,551.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,551.50
|
| Rate for Payer: Cash Price |
$2,268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,126.25
|
| Rate for Payer: Medical Associates Commercial |
$2,126.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,984.50
|
| Rate for Payer: United Healthcare Commercial |
$2,551.50
|
|
|
tenecteplase 50 mg IV SDV Inj [VDMC]
|
Facility
|
IP
|
$14,972.44
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
10423770
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10,480.71 |
| Max. Negotiated Rate |
$13,475.20 |
| Rate for Payer: Aetna of IA Commercial |
$13,475.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13,475.20
|
| Rate for Payer: Cash Price |
$11,977.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11,229.33
|
| Rate for Payer: Medical Associates Commercial |
$11,229.33
|
| Rate for Payer: Midlands Choice Commercial |
$10,480.71
|
| Rate for Payer: United Healthcare Commercial |
$13,475.20
|
|
|
tenecteplase 50 mg IV SDV Inj [VDMC]
|
Facility
|
OP
|
$14,972.44
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
10423770
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6,737.60 |
| Max. Negotiated Rate |
$13,475.20 |
| Rate for Payer: Aetna of IA Commercial |
$13,475.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13,475.20
|
| Rate for Payer: Aetna of IA Medicare |
$8,534.29
|
| Rate for Payer: Amerigroup Medicaid |
$8,636.10
|
| Rate for Payer: Amerigroup Medicare |
$6,804.97
|
| Rate for Payer: Cash Price |
$11,977.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11,229.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6,737.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,552.26
|
| Rate for Payer: Medical Associates Commercial |
$11,229.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$6,737.60
|
| Rate for Payer: Midlands Choice Commercial |
$10,480.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,678.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$7,748.24
|
| Rate for Payer: United Healthcare Commercial |
$13,475.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$8,833.74
|
|
|
terazosin 1 mg Cap [VDMC]
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423837
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna of IA Commercial |
$1.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.31
|
| Rate for Payer: Aetna of IA Medicare |
$0.83
|
| Rate for Payer: Amerigroup Medicaid |
$0.84
|
| Rate for Payer: Amerigroup Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.83
|
| Rate for Payer: Medical Associates Commercial |
$1.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.66
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.75
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.86
|
|
|
terazosin 1 mg Cap [VDMC]
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423837
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna of IA Commercial |
$1.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.31
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.09
|
| Rate for Payer: Medical Associates Commercial |
$1.09
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.31
|
|
|
terazosin 5 mg Cap [VDMC]
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of IA Commercial |
$1.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.34
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: United Healthcare Commercial |
$1.34
|
|
|
terazosin 5 mg Cap [VDMC]
|
Facility
|
OP
|
$1.49
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of IA Commercial |
$1.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.34
|
| Rate for Payer: Aetna of IA Medicare |
$0.85
|
| Rate for Payer: Amerigroup Medicaid |
$0.86
|
| Rate for Payer: Amerigroup Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.85
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.67
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.77
|
| Rate for Payer: United Healthcare Commercial |
$1.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.88
|
|
|
terbinafine 250 mg Tab [VDMC]
|
Facility
|
IP
|
$2.07
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423975
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna of IA Commercial |
$1.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.87
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.55
|
| Rate for Payer: Medical Associates Commercial |
$1.55
|
| Rate for Payer: Midlands Choice Commercial |
$1.45
|
| Rate for Payer: United Healthcare Commercial |
$1.87
|
|
|
terbinafine 250 mg Tab [VDMC]
|
Facility
|
OP
|
$2.07
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423975
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna of IA Commercial |
$1.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.87
|
| Rate for Payer: Aetna of IA Medicare |
$1.18
|
| Rate for Payer: Amerigroup Medicaid |
$1.20
|
| Rate for Payer: Amerigroup Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.55
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.18
|
| Rate for Payer: Medical Associates Commercial |
$1.55
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.93
|
| Rate for Payer: Midlands Choice Commercial |
$1.45
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.07
|
| Rate for Payer: United Healthcare Commercial |
$1.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.22
|
|
