|
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
|
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 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-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
|
OP
|
$2.19
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| 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: Aetna of IA Medicare |
$1.25
|
| Rate for Payer: Amerigroup Medicaid |
$1.26
|
| Rate for Payer: Amerigroup Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.99
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.25
|
| Rate for Payer: Medical Associates Commercial |
$1.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.99
|
| Rate for Payer: Midlands Choice Commercial |
$1.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.13
|
| Rate for Payer: United Healthcare Commercial |
$1.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.29
|
|
|
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
|
|
|
amphotericin B liposomal 50 mg IV Inj SDV [VDMC]
|
Facility
|
OP
|
$289.84
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
10366798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$130.43 |
| Max. Negotiated Rate |
$260.86 |
| Rate for Payer: Aetna of IA Commercial |
$260.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$260.86
|
| Rate for Payer: Aetna of IA Medicare |
$165.21
|
| Rate for Payer: Amerigroup Medicaid |
$167.18
|
| Rate for Payer: Amerigroup Medicare |
$131.73
|
| Rate for Payer: Cash Price |
$231.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$217.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$130.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$165.56
|
| Rate for Payer: Medical Associates Commercial |
$217.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$130.43
|
| Rate for Payer: Midlands Choice Commercial |
$202.89
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$167.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$149.99
|
| Rate for Payer: United Healthcare Commercial |
$260.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$171.01
|
|
|
amphotericin B liposomal 50 mg IV Inj SDV [VDMC]
|
Facility
|
IP
|
$289.84
|
|
|
Service Code
|
HCPCS J0289
|
| Hospital Charge Code |
10366798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$202.89 |
| Max. Negotiated Rate |
$260.86 |
| Rate for Payer: Aetna of IA Commercial |
$260.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$260.86
|
| Rate for Payer: Cash Price |
$231.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$217.38
|
| Rate for Payer: Medical Associates Commercial |
$217.38
|
| Rate for Payer: Midlands Choice Commercial |
$202.89
|
| Rate for Payer: United Healthcare Commercial |
$260.86
|
|
|
ampicillin 1 g Inj SDV [VDMC]
|
Facility
|
IP
|
$24.82
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10366865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.37 |
| Max. Negotiated Rate |
$22.34 |
| Rate for Payer: Aetna of IA Commercial |
$22.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.34
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.62
|
| Rate for Payer: Medical Associates Commercial |
$18.62
|
| Rate for Payer: Midlands Choice Commercial |
$17.37
|
| Rate for Payer: United Healthcare Commercial |
$22.34
|
|
|
ampicillin 1 g Inj SDV [VDMC]
|
Facility
|
OP
|
$24.82
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10366865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.17 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$22.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.34
|
| Rate for Payer: Aetna of IA Medicare |
$14.15
|
| Rate for Payer: Amerigroup Medicaid |
$14.32
|
| Rate for Payer: Amerigroup Medicare |
$11.28
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Cash Price |
$19.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.17
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.18
|
| Rate for Payer: Medical Associates Commercial |
$18.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.17
|
| Rate for Payer: Midlands Choice Commercial |
$17.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.84
|
| Rate for Payer: United Healthcare Commercial |
$22.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.64
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ampicillin 2 g Inj SDV [VDMC]
|
Facility
|
OP
|
$28.57
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10367003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.86 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$25.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.71
|
| Rate for Payer: Aetna of IA Medicare |
$16.28
|
| Rate for Payer: Amerigroup Medicaid |
$16.48
|
| Rate for Payer: Amerigroup Medicare |
$12.98
|
| Rate for Payer: Cash Price |
$22.85
|
| Rate for Payer: Cash Price |
$22.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.32
|
| Rate for Payer: Medical Associates Commercial |
$21.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.86
|
| Rate for Payer: Midlands Choice Commercial |
$20.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.78
|
| Rate for Payer: United Healthcare Commercial |
$25.71
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.86
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ampicillin 2 g Inj SDV [VDMC]
|
Facility
|
IP
|
$28.57
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10367003
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$25.71 |
| Rate for Payer: Aetna of IA Commercial |
$25.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.71
|
| Rate for Payer: Cash Price |
$22.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.43
|
| Rate for Payer: Medical Associates Commercial |
$21.43
|
| Rate for Payer: Midlands Choice Commercial |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$25.71
|
|
|
ampicillin 500 mg Cap [VDMC]
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
HCPCS a9270
|
| Hospital Charge Code |
28497464
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna of IA Commercial |
$2.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.31
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.93
|
| Rate for Payer: Medical Associates Commercial |
$1.93
|
| Rate for Payer: Midlands Choice Commercial |
$1.80
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
|
|
ampicillin 500 mg Cap [VDMC]
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
HCPCS a9270
|
| Hospital Charge Code |
28497464
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna of IA Commercial |
$2.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.31
|
| Rate for Payer: Aetna of IA Medicare |
$1.46
|
| Rate for Payer: Amerigroup Medicaid |
$1.48
|
| Rate for Payer: Amerigroup Medicare |
$1.17
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.93
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.47
|
| Rate for Payer: Medical Associates Commercial |
$1.93
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.16
|
| Rate for Payer: Midlands Choice Commercial |
$1.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.33
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.51
|
|
|
ampicillin 500 mg Inj SDV [VDMC]
|
Facility
|
OP
|
$23.32
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10367072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.98
|
| Rate for Payer: Aetna of IA Medicare |
$13.29
|
| Rate for Payer: Amerigroup Medicaid |
$13.45
|
| Rate for Payer: Amerigroup Medicare |
$10.60
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.49
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.32
|
| Rate for Payer: Medical Associates Commercial |
$17.49
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.49
|
| Rate for Payer: Midlands Choice Commercial |
$16.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.07
|
| Rate for Payer: United Healthcare Commercial |
$20.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.76
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ampicillin 500 mg Inj SDV [VDMC]
|
Facility
|
IP
|
$23.32
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
10367072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$20.98 |
| Rate for Payer: Aetna of IA Commercial |
$20.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.98
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.49
|
| Rate for Payer: Medical Associates Commercial |
$17.49
|
| Rate for Payer: Midlands Choice Commercial |
$16.32
|
| Rate for Payer: United Healthcare Commercial |
$20.98
|
|
|
ampicillin-sulbactam 1.5 GM Inj SDV [VDMC]
|
Facility
|
OP
|
$25.04
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
10367141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$22.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.54
|
| Rate for Payer: Aetna of IA Medicare |
$14.28
|
| Rate for Payer: Amerigroup Medicaid |
$14.45
|
| Rate for Payer: Amerigroup Medicare |
$11.38
|
| Rate for Payer: Cash Price |
$20.04
|
| Rate for Payer: Cash Price |
$20.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.31
|
| Rate for Payer: Medical Associates Commercial |
$18.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.27
|
| Rate for Payer: Midlands Choice Commercial |
$17.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.96
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.78
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ampicillin-sulbactam 1.5 GM Inj SDV [VDMC]
|
Facility
|
IP
|
$25.04
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
10367141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.53 |
| Max. Negotiated Rate |
$22.54 |
| Rate for Payer: Aetna of IA Commercial |
$22.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.54
|
| Rate for Payer: Cash Price |
$20.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.78
|
| Rate for Payer: Medical Associates Commercial |
$18.78
|
| Rate for Payer: Midlands Choice Commercial |
$17.53
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
|
|
ampicillin-sulbactam 3 GM Inj SDV [VDMC]
|
Facility
|
IP
|
$31.59
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
10367210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$28.43 |
| Rate for Payer: Aetna of IA Commercial |
$28.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.43
|
| Rate for Payer: Cash Price |
$25.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.69
|
| Rate for Payer: Medical Associates Commercial |
$23.69
|
| Rate for Payer: Midlands Choice Commercial |
$22.11
|
| Rate for Payer: United Healthcare Commercial |
$28.43
|
|
|
ampicillin-sulbactam 3 GM Inj SDV [VDMC]
|
Facility
|
OP
|
$31.59
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
10367210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.22 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$28.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.43
|
| Rate for Payer: Aetna of IA Medicare |
$18.01
|
| Rate for Payer: Amerigroup Medicaid |
$18.22
|
| Rate for Payer: Amerigroup Medicare |
$14.36
|
| Rate for Payer: Cash Price |
$25.27
|
| Rate for Payer: Cash Price |
$25.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.05
|
| Rate for Payer: Medical Associates Commercial |
$23.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.22
|
| Rate for Payer: Midlands Choice Commercial |
$22.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.35
|
| Rate for Payer: United Healthcare Commercial |
$28.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.64
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
AMPUTATE METATARSAL WITH TOE SINGLE
|
Professional
|
Both
|
$1,453.00
|
|
|
Service Code
|
CPT 28810
|
| Hospital Charge Code |
8825539
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$416.95 |
| Max. Negotiated Rate |
$1,089.75 |
| Rate for Payer: Amerigroup Medicaid |
$421.03
|
| Rate for Payer: Cash Price |
$1,162.40
|
| Rate for Payer: Cash Price |
$1,162.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$416.95
|
| Rate for Payer: Medical Associates Commercial |
$1,089.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,017.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$418.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,089.75
|
| Rate for Payer: United Healthcare Commercial |
$653.39
|
| Rate for Payer: Wellmark IA HMO WHPI |
$801.30
|
| Rate for Payer: Wellmark IA PPO |
$942.80
|
|
