|
tobramycin-dexamethasone Ophth 0.3%-0.1% Susp [VDMC]
|
Facility
|
IP
|
$142.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10381970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$100.04 |
| Max. Negotiated Rate |
$128.63 |
| Rate for Payer: Aetna of IA Commercial |
$128.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.63
|
| Rate for Payer: Cash Price |
$114.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.19
|
| Rate for Payer: Medical Associates Commercial |
$107.19
|
| Rate for Payer: Midlands Choice Commercial |
$100.04
|
| Rate for Payer: United Healthcare Commercial |
$128.63
|
|
|
tobramycin-dexamethasone Ophth 0.3%-0.1% Susp [VDMC]
|
Facility
|
OP
|
$142.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10381970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.31 |
| Max. Negotiated Rate |
$128.63 |
| Rate for Payer: Aetna of IA Commercial |
$128.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.63
|
| Rate for Payer: Aetna of IA Medicare |
$81.46
|
| Rate for Payer: Amerigroup Medicaid |
$82.44
|
| Rate for Payer: Amerigroup Medicare |
$64.96
|
| Rate for Payer: Cash Price |
$114.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.64
|
| Rate for Payer: Medical Associates Commercial |
$107.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.31
|
| Rate for Payer: Midlands Choice Commercial |
$100.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$73.96
|
| Rate for Payer: United Healthcare Commercial |
$128.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.32
|
|
|
Tobramycin Level Trough DMCL
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
8037817
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$138.60 |
| Rate for Payer: Aetna of IA Commercial |
$138.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$138.60
|
| Rate for Payer: Cash Price |
$123.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$115.50
|
| Rate for Payer: Medical Associates Commercial |
$115.50
|
| Rate for Payer: Midlands Choice Commercial |
$107.80
|
| Rate for Payer: United Healthcare Commercial |
$138.60
|
|
|
Tobramycin Level Trough DMCL
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
8037817
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$138.60 |
| Rate for Payer: Aetna of IA Commercial |
$138.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$138.60
|
| Rate for Payer: Aetna of IA Medicare |
$87.78
|
| Rate for Payer: Amerigroup Medicaid |
$88.83
|
| Rate for Payer: Amerigroup Medicare |
$69.99
|
| Rate for Payer: Cash Price |
$123.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$115.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$69.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$87.96
|
| Rate for Payer: Medical Associates Commercial |
$115.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$69.30
|
| Rate for Payer: Midlands Choice Commercial |
$107.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$89.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$79.69
|
| Rate for Payer: United Healthcare Commercial |
$138.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$90.86
|
|
|
tobramycin Ophth 0.3% 5 ml Sol [VDMC]
|
Facility
|
OP
|
$33.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10439585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$29.74 |
| Rate for Payer: Aetna of IA Commercial |
$29.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.74
|
| Rate for Payer: Aetna of IA Medicare |
$18.83
|
| Rate for Payer: Amerigroup Medicaid |
$19.06
|
| Rate for Payer: Amerigroup Medicare |
$15.02
|
| Rate for Payer: Cash Price |
$26.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.87
|
| Rate for Payer: Medical Associates Commercial |
$24.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.87
|
| Rate for Payer: Midlands Choice Commercial |
$23.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.10
|
| Rate for Payer: United Healthcare Commercial |
$29.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.49
|
|
|
tobramycin Ophth 0.3% 5 ml Sol [VDMC]
|
Facility
|
IP
|
$33.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10439585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.13 |
| Max. Negotiated Rate |
$29.74 |
| Rate for Payer: Aetna of IA Commercial |
$29.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.74
|
| Rate for Payer: Cash Price |
$26.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.78
|
| Rate for Payer: Medical Associates Commercial |
$24.78
|
| Rate for Payer: Midlands Choice Commercial |
$23.13
|
| Rate for Payer: United Healthcare Commercial |
$29.74
|
|
|
tolterodine 2 mg Tab [VDMC]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of IA Commercial |
$1.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.70
|
| Rate for Payer: Aetna of IA Medicare |
$1.08
|
| Rate for Payer: Amerigroup Medicaid |
$1.09
|
| Rate for Payer: Amerigroup Medicare |
$0.86
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$1.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.12
|
|
|
tolterodine 2 mg Tab [VDMC]
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of IA Commercial |
$1.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.70
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.42
|
| Rate for Payer: Medical Associates Commercial |
$1.42
|
| Rate for Payer: Midlands Choice Commercial |
$1.32
|
| Rate for Payer: United Healthcare Commercial |
$1.70
|
|
|
topiramate 100 mg Tab [VDMC]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10430641
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Midlands Choice Commercial |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
|
|
topiramate 100 mg Tab [VDMC]
|
Facility
|
OP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10430641
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Aetna of IA Medicare |
$1.28
|
| Rate for Payer: Amerigroup Medicaid |
$1.30
|
| Rate for Payer: Amerigroup Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.28
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.01
|
| Rate for Payer: Midlands Choice Commercial |
$1.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
|
topiramate 25 mg Tab [VDMC]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10608721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of IA Commercial |
$1.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.60
|
| Rate for Payer: Aetna of IA Medicare |
$1.02
|
| Rate for Payer: Amerigroup Medicaid |
$1.03
|
| Rate for Payer: Amerigroup Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.02
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.80
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.05
|
|
|
topiramate 25 mg Tab [VDMC]
|
Facility
|
IP
|
$1.78
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10608721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of IA Commercial |
$1.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.60
|
| Rate for Payer: Cash Price |
$1.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.34
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: United Healthcare Commercial |
$1.60
|
|
|
Topiramate Level DMCL
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
8037818
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$51.30 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$65.76
|
| Rate for Payer: Amerigroup Medicare |
$51.81
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.12
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.30
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$58.99
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
|
|
Topiramate Level DMCL
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
8037818
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
TORPEDO, 4.00MM X 13CM
|
Facility
|
OP
|
$182.00
|
|
| Hospital Charge Code |
8047073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of IA Commercial |
$163.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$163.80
|
| Rate for Payer: Aetna of IA Medicare |
$103.74
|
| Rate for Payer: Amerigroup Medicaid |
$104.98
|
| Rate for Payer: Amerigroup Medicare |
$82.72
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$136.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$103.96
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.90
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$105.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$94.19
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$107.38
|
|
|
TORPEDO, 4.00MM X 13CM
|
Facility
|
IP
|
$182.00
|
|
| Hospital Charge Code |
8047073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of IA Commercial |
$163.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$163.80
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$136.50
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
|
|
TORPEDO, 4.00MMX7CM
|
Facility
|
IP
|
$182.00
|
|
| Hospital Charge Code |
8026442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of IA Commercial |
$163.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$163.80
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$136.50
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
|
|
TORPEDO, 4.00MMX7CM
|
Facility
|
OP
|
$182.00
|
|
| Hospital Charge Code |
8026442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of IA Commercial |
$163.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$163.80
|
| Rate for Payer: Aetna of IA Medicare |
$103.74
|
| Rate for Payer: Amerigroup Medicaid |
$104.98
|
| Rate for Payer: Amerigroup Medicare |
$82.72
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$136.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$103.96
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.90
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$105.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$94.19
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$107.38
|
|
|
torsemide 20 mg Tab [VDMC]
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna of IA Commercial |
$1.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.84
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.53
|
| Rate for Payer: Medical Associates Commercial |
$1.53
|
| Rate for Payer: Midlands Choice Commercial |
$1.43
|
| Rate for Payer: United Healthcare Commercial |
$1.84
|
|
|
torsemide 20 mg Tab [VDMC]
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425568
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna of IA Commercial |
$1.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.84
|
| Rate for Payer: Aetna of IA Medicare |
$1.16
|
| Rate for Payer: Amerigroup Medicaid |
$1.18
|
| Rate for Payer: Amerigroup Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.53
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.17
|
| Rate for Payer: Medical Associates Commercial |
$1.53
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.92
|
| Rate for Payer: Midlands Choice Commercial |
$1.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.06
|
| Rate for Payer: United Healthcare Commercial |
$1.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.21
|
|
|
torsemide 5mg Tab [VDMC]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23356518
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of IA Commercial |
$1.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.62
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.35
|
| Rate for Payer: Medical Associates Commercial |
$1.35
|
| Rate for Payer: Midlands Choice Commercial |
$1.26
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
|
|
torsemide 5mg Tab [VDMC]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23356518
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of IA Commercial |
$1.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.62
|
| Rate for Payer: Aetna of IA Medicare |
$1.03
|
| Rate for Payer: Amerigroup Medicaid |
$1.04
|
| Rate for Payer: Amerigroup Medicare |
$0.82
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.81
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.03
|
| Rate for Payer: Medical Associates Commercial |
$1.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.81
|
| Rate for Payer: Midlands Choice Commercial |
$1.26
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.06
|
|
|
Total Joint Anesthetic Cocktail [VDMC]
|
Facility
|
IP
|
$135.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
29083276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$94.64 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna of IA Commercial |
$121.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.68
|
| Rate for Payer: Cash Price |
$108.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$101.40
|
| Rate for Payer: Medical Associates Commercial |
$101.40
|
| Rate for Payer: Midlands Choice Commercial |
$94.64
|
| Rate for Payer: United Healthcare Commercial |
$121.68
|
|
|
Total Joint Anesthetic Cocktail [VDMC]
|
Facility
|
OP
|
$135.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
29083276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.84 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna of IA Commercial |
$121.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.68
|
| Rate for Payer: Aetna of IA Medicare |
$77.06
|
| Rate for Payer: Amerigroup Medicaid |
$77.98
|
| Rate for Payer: Amerigroup Medicare |
$61.45
|
| Rate for Payer: Cash Price |
$108.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$101.40
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$60.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$77.23
|
| Rate for Payer: Medical Associates Commercial |
$101.40
|
| Rate for Payer: Medical Associates Managed Medicare |
$60.84
|
| Rate for Payer: Midlands Choice Commercial |
$94.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$78.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$69.97
|
| Rate for Payer: United Healthcare Commercial |
$121.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$79.77
|
|
|
TOTAL PROTEIN
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 84155
|
| Hospital Charge Code |
8093946
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Aetna of IA Medicare |
$22.80
|
| Rate for Payer: Amerigroup Medicaid |
$23.07
|
| Rate for Payer: Amerigroup Medicare |
$18.18
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.85
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.70
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
|
