|
ALS1 NON EMERGENCY
|
Facility
|
IP
|
$464.00
|
|
|
Service Code
|
HCPCS A0426 QN
|
| Hospital Charge Code |
5230782
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$324.80 |
| Max. Negotiated Rate |
$417.60 |
| Rate for Payer: Aetna of IA Commercial |
$417.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$417.60
|
| Rate for Payer: Cash Price |
$371.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$348.00
|
| Rate for Payer: Medical Associates Commercial |
$348.00
|
| Rate for Payer: Midlands Choice Commercial |
$324.80
|
| Rate for Payer: United Healthcare Commercial |
$417.60
|
|
|
ALS1 NON EMERGENCY
|
Facility
|
OP
|
$464.00
|
|
|
Service Code
|
HCPCS A0426 QN
|
| Hospital Charge Code |
5230782
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$208.80 |
| Max. Negotiated Rate |
$417.60 |
| Rate for Payer: Aetna of IA Commercial |
$417.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$417.60
|
| Rate for Payer: Aetna of IA Medicare |
$264.48
|
| Rate for Payer: Amerigroup Medicaid |
$267.64
|
| Rate for Payer: Amerigroup Medicare |
$210.89
|
| Rate for Payer: Cash Price |
$371.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$348.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$208.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$265.04
|
| Rate for Payer: Medical Associates Commercial |
$348.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$208.80
|
| Rate for Payer: Midlands Choice Commercial |
$324.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$268.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$240.12
|
| Rate for Payer: United Healthcare Commercial |
$417.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$394.40
|
|
|
ALS2 EMERGENCY
|
Facility
|
IP
|
$1,187.00
|
|
|
Service Code
|
HCPCS A0433 QN
|
| Hospital Charge Code |
5230787
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$830.90 |
| Max. Negotiated Rate |
$1,068.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,068.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,068.30
|
| Rate for Payer: Cash Price |
$949.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$890.25
|
| Rate for Payer: Medical Associates Commercial |
$890.25
|
| Rate for Payer: Midlands Choice Commercial |
$830.90
|
| Rate for Payer: United Healthcare Commercial |
$1,068.30
|
|
|
ALS2 EMERGENCY
|
Facility
|
OP
|
$1,187.00
|
|
|
Service Code
|
HCPCS A0433 QN
|
| Hospital Charge Code |
5230787
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$534.15 |
| Max. Negotiated Rate |
$1,068.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,068.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,068.30
|
| Rate for Payer: Aetna of IA Medicare |
$676.59
|
| Rate for Payer: Amerigroup Medicaid |
$684.66
|
| Rate for Payer: Amerigroup Medicare |
$539.49
|
| Rate for Payer: Cash Price |
$949.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$890.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$534.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$678.01
|
| Rate for Payer: Medical Associates Commercial |
$890.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$534.15
|
| Rate for Payer: Midlands Choice Commercial |
$830.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$687.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$614.27
|
| Rate for Payer: United Healthcare Commercial |
$1,068.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,008.95
|
|
|
alteplase 100 mg IV Inj SDV [VDMC]
|
Facility
|
IP
|
$17,084.70
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
10365213
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11,959.29 |
| Max. Negotiated Rate |
$15,376.23 |
| Rate for Payer: Aetna of IA Commercial |
$15,376.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15,376.23
|
| Rate for Payer: Cash Price |
$13,667.76
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12,813.52
|
| Rate for Payer: Medical Associates Commercial |
$12,813.52
|
| Rate for Payer: Midlands Choice Commercial |
$11,959.29
|
| Rate for Payer: United Healthcare Commercial |
$15,376.23
|
|
|
alteplase 100 mg IV Inj SDV [VDMC]
|
Facility
|
OP
|
$17,084.70
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
10365213
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7,688.12 |
| Max. Negotiated Rate |
$15,376.23 |
| Rate for Payer: Aetna of IA Commercial |
$15,376.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15,376.23
|
| Rate for Payer: Aetna of IA Medicare |
$9,738.28
|
| Rate for Payer: Amerigroup Medicaid |
$9,854.45
|
| Rate for Payer: Amerigroup Medicare |
$7,765.00
|
| Rate for Payer: Cash Price |
$13,667.76
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12,813.52
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7,688.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9,758.78
|
| Rate for Payer: Medical Associates Commercial |
$12,813.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$7,688.12
|
| Rate for Payer: Midlands Choice Commercial |
$11,959.29
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9,902.29
|
| Rate for Payer: Partners Health Alliance Commercial |
$8,841.33
|
| Rate for Payer: United Healthcare Commercial |
$15,376.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$10,079.97
|
|
|
alteplase 2 mg IV Inj SDV [VDMC]
|
Facility
|
IP
|
$734.76
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
10365280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$514.33 |
| Max. Negotiated Rate |
$661.28 |
| Rate for Payer: Aetna of IA Commercial |
$661.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$661.28
|
| Rate for Payer: Cash Price |
$587.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$551.07
|
| Rate for Payer: Medical Associates Commercial |
$551.07
|
| Rate for Payer: Midlands Choice Commercial |
$514.33
|
| Rate for Payer: United Healthcare Commercial |
$661.28
|
|
|
alteplase 2 mg IV Inj SDV [VDMC]
|
Facility
|
OP
|
$734.76
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
10365280
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$330.64 |
| Max. Negotiated Rate |
$661.28 |
| Rate for Payer: Aetna of IA Commercial |
$661.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$661.28
|
| Rate for Payer: Aetna of IA Medicare |
$418.81
|
| Rate for Payer: Amerigroup Medicaid |
$423.81
|
| Rate for Payer: Amerigroup Medicare |
$333.95
|
| Rate for Payer: Cash Price |
$587.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$551.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$330.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$419.69
|
| Rate for Payer: Medical Associates Commercial |
$551.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$330.64
|
| Rate for Payer: Midlands Choice Commercial |
$514.33
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$425.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$380.24
|
| Rate for Payer: United Healthcare Commercial |
$661.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$433.51
|
|
|
ALT (SGPT)
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 84460
|
| Hospital Charge Code |
633632
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna of IA Commercial |
$45.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.90
|
| Rate for Payer: Aetna of IA Medicare |
$29.07
|
| Rate for Payer: Amerigroup Medicaid |
$29.42
|
| Rate for Payer: Amerigroup Medicare |
$23.18
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$29.13
|
| Rate for Payer: Medical Associates Commercial |
$38.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.95
|
| Rate for Payer: Midlands Choice Commercial |
$35.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.39
|
| Rate for Payer: United Healthcare Commercial |
$45.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.09
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
ALT (SGPT)
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 84460
|
| Hospital Charge Code |
633632
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna of IA Commercial |
$45.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.90
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.25
|
| Rate for Payer: Medical Associates Commercial |
$38.25
|
| Rate for Payer: Midlands Choice Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$45.90
|
|
|
amantadine 100 mg Cap [VDMC]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10365416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of IA Commercial |
$1.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.20
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Midlands Choice Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
amantadine 100 mg Cap [VDMC]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10365416
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of IA Commercial |
$1.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.20
|
| Rate for Payer: Aetna of IA Medicare |
$0.76
|
| Rate for Payer: Amerigroup Medicaid |
$0.77
|
| Rate for Payer: Amerigroup Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| 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 |
$0.76
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.60
|
| Rate for Payer: Midlands Choice Commercial |
$0.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.69
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.78
|
|
|
amantadine 50 mg/5 mL Syr [VDMC]
|
Facility
|
IP
|
$7.86
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11221210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$7.08 |
| Rate for Payer: Aetna of IA Commercial |
$7.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.08
|
| Rate for Payer: Cash Price |
$6.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.90
|
| Rate for Payer: Medical Associates Commercial |
$5.90
|
| Rate for Payer: Midlands Choice Commercial |
$5.50
|
| Rate for Payer: United Healthcare Commercial |
$7.08
|
|
|
amantadine 50 mg/5 mL Syr [VDMC]
|
Facility
|
OP
|
$7.86
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11221210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$7.08 |
| Rate for Payer: Aetna of IA Commercial |
$7.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.08
|
| Rate for Payer: Aetna of IA Medicare |
$4.48
|
| Rate for Payer: Amerigroup Medicaid |
$4.53
|
| Rate for Payer: Amerigroup Medicare |
$3.57
|
| Rate for Payer: Cash Price |
$6.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.49
|
| Rate for Payer: Medical Associates Commercial |
$5.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.54
|
| Rate for Payer: Midlands Choice Commercial |
$5.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.07
|
| Rate for Payer: United Healthcare Commercial |
$7.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.64
|
|
|
AMB RESPOND TREAT/NO TRANSPORT
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS A0998 QN
|
| Hospital Charge Code |
7932767
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna of IA Commercial |
$106.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$106.20
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$88.50
|
| Rate for Payer: Medical Associates Commercial |
$88.50
|
| Rate for Payer: Midlands Choice Commercial |
$82.60
|
| Rate for Payer: United Healthcare Commercial |
$106.20
|
|
|
AMB RESPOND TREAT/NO TRANSPORT
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS A0998 QN
|
| Hospital Charge Code |
7932767
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$53.10 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna of IA Commercial |
$106.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$106.20
|
| Rate for Payer: Aetna of IA Medicare |
$67.26
|
| Rate for Payer: Amerigroup Medicaid |
$68.06
|
| Rate for Payer: Amerigroup Medicare |
$53.63
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$88.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.40
|
| Rate for Payer: Medical Associates Commercial |
$88.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.10
|
| Rate for Payer: Midlands Choice Commercial |
$82.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.06
|
| Rate for Payer: United Healthcare Commercial |
$106.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.30
|
|
|
Amikacin Level Trough DMCL
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
8037492
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of IA Commercial |
$55.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.80
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.50
|
| Rate for Payer: Medical Associates Commercial |
$46.50
|
| Rate for Payer: Midlands Choice Commercial |
$43.40
|
| Rate for Payer: United Healthcare Commercial |
$55.80
|
|
|
Amikacin Level Trough DMCL
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
8037492
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$71.85 |
| Rate for Payer: Aetna of IA Commercial |
$55.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.80
|
| Rate for Payer: Aetna of IA Medicare |
$35.34
|
| Rate for Payer: Amerigroup Medicaid |
$35.76
|
| Rate for Payer: Amerigroup Medicare |
$28.18
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.41
|
| Rate for Payer: Medical Associates Commercial |
$46.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.90
|
| Rate for Payer: Midlands Choice Commercial |
$43.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.08
|
| Rate for Payer: United Healthcare Commercial |
$55.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.58
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
aMILoride 5 mg Tab [VDMC]
|
Facility
|
OP
|
$1.73
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10365556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of IA Commercial |
$1.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.56
|
| Rate for Payer: Aetna of IA Medicare |
$0.99
|
| Rate for Payer: Amerigroup Medicaid |
$1.00
|
| Rate for Payer: Amerigroup Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.99
|
| Rate for Payer: Medical Associates Commercial |
$1.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.78
|
| Rate for Payer: Midlands Choice Commercial |
$1.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.02
|
|
|
aMILoride 5 mg Tab [VDMC]
|
Facility
|
IP
|
$1.73
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10365556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of IA Commercial |
$1.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.56
|
| Rate for Payer: Cash Price |
$1.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.30
|
| Rate for Payer: Medical Associates Commercial |
$1.30
|
| Rate for Payer: Midlands Choice Commercial |
$1.21
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
|
|
Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) intravenous solution Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) Sol
|
Facility
|
IP
|
$363.20
|
|
|
Service Code
|
NDC 00338-7032-04
|
| Hospital Charge Code |
29229689
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$254.24 |
| Max. Negotiated Rate |
$326.88 |
| Rate for Payer: Aetna of IA Commercial |
$326.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$326.88
|
| Rate for Payer: Cash Price |
$290.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$272.40
|
| Rate for Payer: Medical Associates Commercial |
$272.40
|
| Rate for Payer: Midlands Choice Commercial |
$254.24
|
| Rate for Payer: United Healthcare Commercial |
$326.88
|
|
|
Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) intravenous solution Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) Sol
|
Facility
|
OP
|
$363.20
|
|
|
Service Code
|
NDC 00338-7032-04
|
| Hospital Charge Code |
29229689
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$326.88 |
| Rate for Payer: Aetna of IA Commercial |
$326.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$326.88
|
| Rate for Payer: Aetna of IA Medicare |
$207.02
|
| Rate for Payer: Amerigroup Medicaid |
$209.49
|
| Rate for Payer: Amerigroup Medicare |
$165.07
|
| Rate for Payer: Cash Price |
$290.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$272.40
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$163.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$207.46
|
| Rate for Payer: Medical Associates Commercial |
$272.40
|
| Rate for Payer: Medical Associates Managed Medicare |
$163.44
|
| Rate for Payer: Midlands Choice Commercial |
$254.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$210.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$187.96
|
| Rate for Payer: United Healthcare Commercial |
$326.88
|
| Rate for Payer: United Healthcare Managed Medicare |
$214.29
|
|
|
Amino Acids 5% with 20% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 5% with 20% Dextrose (Clinimix Sulfite-Free) Sol
|
Facility
|
IP
|
$245.40
|
|
|
Service Code
|
NDC 00338-1138-03
|
| Hospital Charge Code |
26547466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$171.78 |
| Max. Negotiated Rate |
$220.86 |
| Rate for Payer: Aetna of IA Commercial |
$220.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$220.86
|
| Rate for Payer: Cash Price |
$196.32
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$184.05
|
| Rate for Payer: Medical Associates Commercial |
$184.05
|
| Rate for Payer: Midlands Choice Commercial |
$171.78
|
| Rate for Payer: United Healthcare Commercial |
$220.86
|
|
|
Amino Acids 5% with 20% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 5% with 20% Dextrose (Clinimix Sulfite-Free) Sol
|
Facility
|
OP
|
$245.40
|
|
|
Service Code
|
NDC 00338-1138-03
|
| Hospital Charge Code |
26547466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$110.43 |
| Max. Negotiated Rate |
$220.86 |
| Rate for Payer: Aetna of IA Commercial |
$220.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$220.86
|
| Rate for Payer: Aetna of IA Medicare |
$139.88
|
| Rate for Payer: Amerigroup Medicaid |
$141.55
|
| Rate for Payer: Amerigroup Medicare |
$111.53
|
| Rate for Payer: Cash Price |
$196.32
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$184.05
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$110.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$140.17
|
| Rate for Payer: Medical Associates Commercial |
$184.05
|
| Rate for Payer: Medical Associates Managed Medicare |
$110.43
|
| Rate for Payer: Midlands Choice Commercial |
$171.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$142.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$126.99
|
| Rate for Payer: United Healthcare Commercial |
$220.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$144.79
|
|
|
aminophylline 25 mg/mL 10 ml IV Sol SDV [VDMC]
|
Facility
|
IP
|
$63.84
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
10365617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.69 |
| Max. Negotiated Rate |
$57.45 |
| Rate for Payer: Aetna of IA Commercial |
$57.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.45
|
| Rate for Payer: Cash Price |
$51.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.88
|
| Rate for Payer: Medical Associates Commercial |
$47.88
|
| Rate for Payer: Midlands Choice Commercial |
$44.69
|
| Rate for Payer: United Healthcare Commercial |
$57.45
|
|
