|
amitriptyline 25 mg Tab [VDMC]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10365897
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of IA Commercial |
$1.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.18
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Midlands Choice Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
|
|
amitriptyline 25 mg Tab [VDMC]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10365897
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of IA Commercial |
$1.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.18
|
| Rate for Payer: Aetna of IA Medicare |
$0.75
|
| Rate for Payer: Amerigroup Medicaid |
$0.76
|
| Rate for Payer: Amerigroup Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.75
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.68
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
amLODIPine-benazepril 5 mg-20 mg Cap [VDMC]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Aetna of IA Commercial |
$1.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.36
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.14
|
| Rate for Payer: Medical Associates Commercial |
$1.14
|
| Rate for Payer: Midlands Choice Commercial |
$1.06
|
| Rate for Payer: United Healthcare Commercial |
$1.36
|
|
|
amLODIPine-benazepril 5 mg-20 mg Cap [VDMC]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Aetna of IA Commercial |
$1.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.36
|
| Rate for Payer: Aetna of IA Medicare |
$0.86
|
| Rate for Payer: Amerigroup Medicaid |
$0.87
|
| Rate for Payer: Amerigroup Medicare |
$0.69
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.87
|
| Rate for Payer: Medical Associates Commercial |
$1.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.68
|
| Rate for Payer: Midlands Choice Commercial |
$1.06
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.78
|
| Rate for Payer: United Healthcare Commercial |
$1.36
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.89
|
|
|
amLODIPine besylate 5 mg Tab [VDMC]
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Aetna of IA Commercial |
$1.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.19
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.99
|
| Rate for Payer: Medical Associates Commercial |
$0.99
|
| Rate for Payer: Midlands Choice Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.19
|
|
|
amLODIPine besylate 5 mg Tab [VDMC]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366106
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Aetna of IA Commercial |
$1.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.19
|
| Rate for Payer: Aetna of IA Medicare |
$0.75
|
| Rate for Payer: Amerigroup Medicaid |
$0.76
|
| Rate for Payer: Amerigroup Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.99
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.75
|
| Rate for Payer: Medical Associates Commercial |
$0.99
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.68
|
| Rate for Payer: United Healthcare Commercial |
$1.19
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.78
|
|
|
AMMONIA
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
1628880
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$85.40 |
| Max. Negotiated Rate |
$109.80 |
| Rate for Payer: Aetna of IA Commercial |
$109.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$109.80
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$91.50
|
| Rate for Payer: Medical Associates Commercial |
$91.50
|
| Rate for Payer: Midlands Choice Commercial |
$85.40
|
| Rate for Payer: United Healthcare Commercial |
$109.80
|
|
|
AMMONIA
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
1628880
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$54.90 |
| Max. Negotiated Rate |
$109.80 |
| Rate for Payer: Aetna of IA Commercial |
$109.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$109.80
|
| Rate for Payer: Aetna of IA Medicare |
$69.54
|
| Rate for Payer: Amerigroup Medicaid |
$70.37
|
| Rate for Payer: Amerigroup Medicare |
$55.45
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$91.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.69
|
| Rate for Payer: Medical Associates Commercial |
$91.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.90
|
| Rate for Payer: Midlands Choice Commercial |
$85.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.13
|
| Rate for Payer: United Healthcare Commercial |
$109.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$71.98
|
|
|
ammonium lactate Top 12% Lotion [VDMC]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10433152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of IA Commercial |
$18.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.00
|
| Rate for Payer: Medical Associates Commercial |
$15.00
|
| Rate for Payer: Midlands Choice Commercial |
$14.00
|
| Rate for Payer: United Healthcare Commercial |
$18.00
|
|
|
ammonium lactate Top 12% Lotion [VDMC]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10433152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of IA Commercial |
$18.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.00
|
| Rate for Payer: Aetna of IA Medicare |
$11.40
|
| Rate for Payer: Amerigroup Medicaid |
$11.53
|
| Rate for Payer: Amerigroup Medicare |
$9.09
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.42
|
| Rate for Payer: Medical Associates Commercial |
$15.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.00
|
| Rate for Payer: Midlands Choice Commercial |
$14.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.35
|
| Rate for Payer: United Healthcare Commercial |
$18.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.80
|
|
|
AMNIOCENTESIS DIAGNOSTIC
|
Facility
|
IP
|
$949.00
|
|
|
Service Code
|
CPT 59000
|
| Hospital Charge Code |
7984751
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$664.30 |
| Max. Negotiated Rate |
$854.10 |
| Rate for Payer: Aetna of IA Commercial |
$854.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$854.10
|
| Rate for Payer: Cash Price |
$759.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$711.75
|
| Rate for Payer: Medical Associates Commercial |
$711.75
|
| Rate for Payer: Midlands Choice Commercial |
$664.30
|
| Rate for Payer: United Healthcare Commercial |
$854.10
|
|
|
AMNIOCENTESIS DIAGNOSTIC
|
Facility
|
OP
|
$949.00
|
|
|
Service Code
|
CPT 59000
|
| Hospital Charge Code |
7984751
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$427.05 |
| Max. Negotiated Rate |
$854.10 |
| Rate for Payer: Aetna of IA Commercial |
$854.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$854.10
|
| Rate for Payer: Aetna of IA Medicare |
$540.93
|
| Rate for Payer: Amerigroup Medicaid |
$547.38
|
| Rate for Payer: Amerigroup Medicare |
$431.32
|
| Rate for Payer: Cash Price |
$759.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$711.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$427.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$542.07
|
| Rate for Payer: Medical Associates Commercial |
$711.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$427.05
|
| Rate for Payer: Midlands Choice Commercial |
$664.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$550.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$491.11
|
| Rate for Payer: United Healthcare Commercial |
$854.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$559.91
|
|
|
AMNION THIN GRAFT 4CMX6CM
|
Facility
|
OP
|
$5,445.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
8782686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,450.25 |
| Max. Negotiated Rate |
$4,900.50 |
| Rate for Payer: Aetna of IA Commercial |
$4,900.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,900.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,103.65
|
| Rate for Payer: Amerigroup Medicaid |
$3,140.68
|
| Rate for Payer: Amerigroup Medicare |
$2,474.75
|
| Rate for Payer: Cash Price |
$4,356.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,083.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,450.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,110.18
|
| Rate for Payer: Medical Associates Commercial |
$4,083.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,450.25
|
| Rate for Payer: Midlands Choice Commercial |
$3,811.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,155.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,817.79
|
| Rate for Payer: United Healthcare Commercial |
$4,900.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,212.55
|
|
|
AMNION THIN GRAFT 4CMX6CM
|
Facility
|
IP
|
$5,445.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
8782686
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,811.50 |
| Max. Negotiated Rate |
$4,900.50 |
| Rate for Payer: Aetna of IA Commercial |
$4,900.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,900.50
|
| Rate for Payer: Cash Price |
$4,356.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,083.75
|
| Rate for Payer: Medical Associates Commercial |
$4,083.75
|
| Rate for Payer: Midlands Choice Commercial |
$3,811.50
|
| Rate for Payer: United Healthcare Commercial |
$4,900.50
|
|
|
amoxicillin 200 mg/5 mL 50ml suspension[VDMC]
|
Facility
|
IP
|
$12.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
13890415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.79 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Aetna of IA Commercial |
$11.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.30
|
| Rate for Payer: Cash Price |
$10.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.42
|
| Rate for Payer: Medical Associates Commercial |
$9.42
|
| Rate for Payer: Midlands Choice Commercial |
$8.79
|
| Rate for Payer: United Healthcare Commercial |
$11.30
|
|
|
amoxicillin 200 mg/5 mL 50ml suspension[VDMC]
|
Facility
|
OP
|
$12.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
13890415
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Aetna of IA Commercial |
$11.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.30
|
| Rate for Payer: Aetna of IA Medicare |
$7.16
|
| Rate for Payer: Amerigroup Medicaid |
$7.24
|
| Rate for Payer: Amerigroup Medicare |
$5.71
|
| Rate for Payer: Cash Price |
$10.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.17
|
| Rate for Payer: Medical Associates Commercial |
$9.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.65
|
| Rate for Payer: Midlands Choice Commercial |
$8.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.50
|
| Rate for Payer: United Healthcare Commercial |
$11.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.41
|
|
|
amoxicillin 400 mg/5 mL 50 ml Pow [VDMC]
|
Facility
|
IP
|
$16.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
13887550
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$14.98 |
| Rate for Payer: Aetna of IA Commercial |
$14.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.98
|
| Rate for Payer: Cash Price |
$13.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.48
|
| Rate for Payer: Medical Associates Commercial |
$12.48
|
| Rate for Payer: Midlands Choice Commercial |
$11.65
|
| Rate for Payer: United Healthcare Commercial |
$14.98
|
|
|
amoxicillin 400 mg/5 mL 50 ml Pow [VDMC]
|
Facility
|
OP
|
$16.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
13887550
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$14.98 |
| Rate for Payer: Aetna of IA Commercial |
$14.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.98
|
| Rate for Payer: Aetna of IA Medicare |
$9.48
|
| Rate for Payer: Amerigroup Medicaid |
$9.60
|
| Rate for Payer: Amerigroup Medicare |
$7.56
|
| Rate for Payer: Cash Price |
$13.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.50
|
| Rate for Payer: Medical Associates Commercial |
$12.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.49
|
| Rate for Payer: Midlands Choice Commercial |
$11.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.61
|
| Rate for Payer: United Healthcare Commercial |
$14.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.82
|
|
|
amoxicillin 500 mg Cap [VDMC]
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10431311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of IA Commercial |
$1.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.39
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
|
|
amoxicillin 500 mg Cap [VDMC]
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10431311
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of IA Commercial |
$1.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.39
|
| Rate for Payer: Aetna of IA Medicare |
$0.88
|
| Rate for Payer: Amerigroup Medicaid |
$0.89
|
| Rate for Payer: Amerigroup Medicare |
$0.70
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.69
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.88
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.69
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.91
|
|
|
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL 75 ML Pow[VDMC]
|
Facility
|
IP
|
$193.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14016315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$135.60 |
| Max. Negotiated Rate |
$174.35 |
| Rate for Payer: Aetna of IA Commercial |
$174.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$174.35
|
| Rate for Payer: Cash Price |
$154.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$145.29
|
| Rate for Payer: Medical Associates Commercial |
$145.29
|
| Rate for Payer: Midlands Choice Commercial |
$135.60
|
| Rate for Payer: United Healthcare Commercial |
$174.35
|
|
|
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL 75 ML Pow[VDMC]
|
Facility
|
OP
|
$193.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14016315
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$87.17 |
| Max. Negotiated Rate |
$174.35 |
| Rate for Payer: Aetna of IA Commercial |
$174.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$174.35
|
| Rate for Payer: Aetna of IA Medicare |
$110.42
|
| Rate for Payer: Amerigroup Medicaid |
$111.74
|
| Rate for Payer: Amerigroup Medicare |
$88.05
|
| Rate for Payer: Cash Price |
$154.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$145.29
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$87.17
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$110.65
|
| Rate for Payer: Medical Associates Commercial |
$145.29
|
| Rate for Payer: Medical Associates Managed Medicare |
$87.17
|
| Rate for Payer: Midlands Choice Commercial |
$135.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$112.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$100.25
|
| Rate for Payer: United Healthcare Commercial |
$174.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$114.29
|
|
|
amoxicillin-clavulanate 500 mg-125 mg Tab [VDMC]
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366660
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of IA Commercial |
$1.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.73
|
| Rate for Payer: Aetna of IA Medicare |
$1.10
|
| Rate for Payer: Amerigroup Medicaid |
$1.11
|
| Rate for Payer: Amerigroup Medicare |
$0.87
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.10
|
| Rate for Payer: Medical Associates Commercial |
$1.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.86
|
| Rate for Payer: Midlands Choice Commercial |
$1.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$1.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.13
|
|
|
amoxicillin-clavulanate 500 mg-125 mg Tab [VDMC]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366660
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of IA Commercial |
$1.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.73
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.44
|
| Rate for Payer: Medical Associates Commercial |
$1.44
|
| Rate for Payer: Midlands Choice Commercial |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$1.73
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [VDMC]
|
Facility
|
IP
|
$2.19
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna of IA Commercial |
$1.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.97
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.64
|
| Rate for Payer: Medical Associates Commercial |
$1.64
|
| Rate for Payer: Midlands Choice Commercial |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.97
|
|
