|
tiZANidine 4 mg Tab [VDMC]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of IA Commercial |
$1.07
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.07
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$0.89
|
| Rate for Payer: Midlands Choice Commercial |
$0.83
|
| Rate for Payer: United Healthcare Commercial |
$1.07
|
|
|
tiZANidine 4 mg Tab [VDMC]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of IA Commercial |
$1.07
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.07
|
| Rate for Payer: Aetna of IA Medicare |
$0.68
|
| Rate for Payer: Amerigroup Medicaid |
$0.60
|
| Rate for Payer: Amerigroup Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.89
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.59
|
| Rate for Payer: Medical Associates Commercial |
$0.89
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.60
|
| Rate for Payer: Midlands Choice Commercial |
$0.83
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.60
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.60
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.89
|
| Rate for Payer: United Healthcare Commercial |
$1.07
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.70
|
|
|
tobramycin-dexamethasone Ophth 0.3%-0.1% Susp [VDMC]
|
Facility
|
IP
|
$169.76
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10381970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$118.83 |
| Max. Negotiated Rate |
$152.78 |
| Rate for Payer: Aetna of IA Commercial |
$152.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$152.78
|
| Rate for Payer: Cash Price |
$135.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.32
|
| Rate for Payer: Medical Associates Commercial |
$127.32
|
| Rate for Payer: Midlands Choice Commercial |
$118.83
|
| Rate for Payer: United Healthcare Commercial |
$152.78
|
|
|
tobramycin-dexamethasone Ophth 0.3%-0.1% Susp [VDMC]
|
Facility
|
OP
|
$169.76
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10381970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$84.85 |
| Max. Negotiated Rate |
$152.78 |
| Rate for Payer: Aetna of IA Commercial |
$152.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$152.78
|
| Rate for Payer: Aetna of IA Medicare |
$96.76
|
| Rate for Payer: Amerigroup Medicaid |
$85.68
|
| Rate for Payer: Amerigroup Medicare |
$85.73
|
| Rate for Payer: Cash Price |
$135.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$84.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$84.85
|
| Rate for Payer: Medical Associates Commercial |
$127.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$84.88
|
| Rate for Payer: Midlands Choice Commercial |
$118.83
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$86.15
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$86.10
|
| Rate for Payer: Oscar Health of IA Commercial |
$127.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$127.32
|
| Rate for Payer: United Healthcare Commercial |
$152.78
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.16
|
|
|
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 |
$49.60 |
| 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 |
$77.72
|
| Rate for Payer: Amerigroup Medicare |
$77.77
|
| Rate for Payer: Cash Price |
$123.20
|
| 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 |
$77.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$76.97
|
| Rate for Payer: Medical Associates Commercial |
$115.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$77.00
|
| Rate for Payer: Midlands Choice Commercial |
$107.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$78.16
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$78.11
|
| Rate for Payer: Oscar Health of IA Commercial |
$115.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$115.50
|
| Rate for Payer: United Healthcare Commercial |
$138.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$90.86
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
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
|
|
|
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 |
$16.51 |
| 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 |
$16.68
|
| Rate for Payer: Amerigroup Medicare |
$16.69
|
| 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 |
$16.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.51
|
| Rate for Payer: Medical Associates Commercial |
$24.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.52
|
| Rate for Payer: Midlands Choice Commercial |
$23.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.77
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$16.76
|
| Rate for Payer: Oscar Health of IA Commercial |
$24.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.78
|
| Rate for Payer: United Healthcare Commercial |
$29.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.49
|
|
|
tocilizumab 20 mg/mL 20ml SDV [VDMC]
|
Facility
|
IP
|
$4,596.32
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
20325498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3,217.42 |
| Max. Negotiated Rate |
$4,136.69 |
| Rate for Payer: Aetna of IA Commercial |
$4,136.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,136.69
|
| Rate for Payer: Cash Price |
$3,677.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,447.24
|
| Rate for Payer: Medical Associates Commercial |
$3,447.24
|
| Rate for Payer: Midlands Choice Commercial |
$3,217.42
|
| Rate for Payer: United Healthcare Commercial |
$4,136.69
|
|
|
tocilizumab 20 mg/mL 20ml SDV [VDMC]
|
Facility
|
OP
|
$4,596.32
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
20325498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,297.24 |
| Max. Negotiated Rate |
$4,136.69 |
| Rate for Payer: Aetna of IA Commercial |
$4,136.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,136.69
|
| Rate for Payer: Aetna of IA Medicare |
$2,619.90
|
| Rate for Payer: Amerigroup Medicaid |
$2,319.76
|
| Rate for Payer: Amerigroup Medicare |
$2,321.14
|
| Rate for Payer: Cash Price |
$3,677.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,447.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,298.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,297.24
|
| Rate for Payer: Medical Associates Commercial |
$3,447.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,298.16
|
| Rate for Payer: Midlands Choice Commercial |
$3,217.42
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,332.63
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$2,331.25
|
| Rate for Payer: Oscar Health of IA Commercial |
$3,447.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,447.24
|
| Rate for Payer: United Healthcare Commercial |
$4,136.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,711.83
|
|
|
tolterodine 2 mg Tab [VDMC]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| 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 |
$0.95
|
| Rate for Payer: Amerigroup Medicare |
$0.95
|
| 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 |
$0.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.94
|
| Rate for Payer: Medical Associates Commercial |
$1.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.95
|
| Rate for Payer: Midlands Choice Commercial |
$1.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.96
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.96
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.42
|
| 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
|
OP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10430641
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| 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 |
$1.14
|
| Rate for Payer: Amerigroup Medicare |
$1.14
|
| 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 |
$1.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.14
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.14
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.69
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
|
topiramate 100 mg Tab [VDMC]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10430641
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| 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 |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
|
|
topiramate 25 mg Tab [VDMC]
|
Facility
|
OP
|
$1.78
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10608721
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.89 |
| 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 |
$1.01
|
| Rate for Payer: Amerigroup Medicaid |
$0.90
|
| Rate for Payer: Amerigroup Medicare |
$0.90
|
| 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 |
$0.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.89
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.90
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.90
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.34
|
| 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 |
$49.60 |
| 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 |
$57.54
|
| Rate for Payer: Amerigroup Medicare |
$57.57
|
| Rate for Payer: Cash Price |
$91.20
|
| 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 |
$57.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.98
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.00
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.86
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$57.82
|
| Rate for Payer: Oscar Health of IA Commercial |
$85.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
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
|
|
|
topotecan 1 mg/mL 4ml SDV Sol [VDMC]
|
Facility
|
IP
|
$176.32
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
21570430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$123.42 |
| Max. Negotiated Rate |
$158.69 |
| Rate for Payer: Aetna of IA Commercial |
$158.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$158.69
|
| Rate for Payer: Cash Price |
$141.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.24
|
| Rate for Payer: Medical Associates Commercial |
$132.24
|
| Rate for Payer: Midlands Choice Commercial |
$123.42
|
| Rate for Payer: United Healthcare Commercial |
$158.69
|
|
|
topotecan 1 mg/mL 4ml SDV Sol [VDMC]
|
Facility
|
OP
|
$176.32
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
21570430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$88.12 |
| Max. Negotiated Rate |
$158.69 |
| Rate for Payer: Aetna of IA Commercial |
$158.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$158.69
|
| Rate for Payer: Aetna of IA Medicare |
$100.50
|
| Rate for Payer: Amerigroup Medicaid |
$88.99
|
| Rate for Payer: Amerigroup Medicare |
$89.04
|
| Rate for Payer: Cash Price |
$141.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$88.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$88.12
|
| Rate for Payer: Medical Associates Commercial |
$132.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$88.16
|
| Rate for Payer: Midlands Choice Commercial |
$123.42
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$89.48
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$89.43
|
| Rate for Payer: Oscar Health of IA Commercial |
$132.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$132.24
|
| Rate for Payer: United Healthcare Commercial |
$158.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$104.03
|
|
|
TORIC LENS 17.0 SN6AT3+17.0D
|
Facility
|
OP
|
$891.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8934814
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$445.32 |
| Max. Negotiated Rate |
$801.90 |
| Rate for Payer: Aetna of IA Commercial |
$801.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$801.90
|
| Rate for Payer: Aetna of IA Medicare |
$507.87
|
| Rate for Payer: Amerigroup Medicaid |
$449.69
|
| Rate for Payer: Amerigroup Medicare |
$449.96
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$668.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$445.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$445.32
|
| Rate for Payer: Medical Associates Commercial |
$668.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$445.50
|
| Rate for Payer: Midlands Choice Commercial |
$623.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$452.18
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$451.92
|
| Rate for Payer: Oscar Health of IA Commercial |
$668.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$668.25
|
| Rate for Payer: United Healthcare Commercial |
$801.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$525.69
|
|
|
TORIC LENS 17.0 SN6AT3+17.0D
|
Facility
|
IP
|
$891.00
|
|
|
Service Code
|
CPT V2787
|
| Hospital Charge Code |
8934814
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$623.70 |
| Max. Negotiated Rate |
$801.90 |
| Rate for Payer: Aetna of IA Commercial |
$801.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$801.90
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$668.25
|
| Rate for Payer: Medical Associates Commercial |
$668.25
|
| Rate for Payer: Midlands Choice Commercial |
$623.70
|
| Rate for Payer: United Healthcare Commercial |
$801.90
|
|
|
TORPEDO, 4.00MM X 13CM
|
Facility
|
OP
|
$182.00
|
|
| Hospital Charge Code |
8047073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.96 |
| 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 |
$91.86
|
| Rate for Payer: Amerigroup Medicare |
$91.91
|
| 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 |
$91.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$90.96
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$91.00
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$92.36
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$92.31
|
| Rate for Payer: Oscar Health of IA Commercial |
$136.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$136.50
|
| 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
|
OP
|
$182.00
|
|
| Hospital Charge Code |
8026442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$90.96 |
| 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 |
$91.86
|
| Rate for Payer: Amerigroup Medicare |
$91.91
|
| 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 |
$91.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$90.96
|
| Rate for Payer: Medical Associates Commercial |
$136.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$91.00
|
| Rate for Payer: Midlands Choice Commercial |
$127.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$92.36
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$92.31
|
| Rate for Payer: Oscar Health of IA Commercial |
$136.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$136.50
|
| Rate for Payer: United Healthcare Commercial |
$163.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$107.38
|
|
