|
timolol ophthalmic maleate 0.5% Sol 2.5ml [VDMC]
|
Facility
|
IP
|
$295.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
20409234
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$206.72 |
| Max. Negotiated Rate |
$265.79 |
| Rate for Payer: Aetna of IA Commercial |
$265.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$265.79
|
| Rate for Payer: Cash Price |
$236.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$221.49
|
| Rate for Payer: Medical Associates Commercial |
$221.49
|
| Rate for Payer: Midlands Choice Commercial |
$206.72
|
| Rate for Payer: United Healthcare Commercial |
$265.79
|
|
|
timolol ophthalmic maleate 0.5% Sol 2.5ml [VDMC]
|
Facility
|
OP
|
$295.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
20409234
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$132.89 |
| Max. Negotiated Rate |
$265.79 |
| Rate for Payer: Aetna of IA Commercial |
$265.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$265.79
|
| Rate for Payer: Aetna of IA Medicare |
$168.33
|
| Rate for Payer: Amerigroup Medicaid |
$170.34
|
| Rate for Payer: Amerigroup Medicare |
$134.22
|
| Rate for Payer: Cash Price |
$236.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$221.49
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$132.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$168.69
|
| Rate for Payer: Medical Associates Commercial |
$221.49
|
| Rate for Payer: Medical Associates Managed Medicare |
$132.89
|
| Rate for Payer: Midlands Choice Commercial |
$206.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$171.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$152.83
|
| Rate for Payer: United Healthcare Commercial |
$265.79
|
| Rate for Payer: United Healthcare Managed Medicare |
$174.24
|
|
|
tiotropium 18 mcg Inh Cap [VDMC]
|
Facility
|
IP
|
$199.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$139.66 |
| Max. Negotiated Rate |
$179.57 |
| Rate for Payer: Aetna of IA Commercial |
$179.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$179.57
|
| Rate for Payer: Cash Price |
$159.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$149.64
|
| Rate for Payer: Medical Associates Commercial |
$149.64
|
| Rate for Payer: Midlands Choice Commercial |
$139.66
|
| Rate for Payer: United Healthcare Commercial |
$179.57
|
|
|
tiotropium 18 mcg Inh Cap [VDMC]
|
Facility
|
OP
|
$199.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$89.78 |
| Max. Negotiated Rate |
$179.57 |
| Rate for Payer: Aetna of IA Commercial |
$179.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$179.57
|
| Rate for Payer: Aetna of IA Medicare |
$113.73
|
| Rate for Payer: Amerigroup Medicaid |
$115.08
|
| Rate for Payer: Amerigroup Medicare |
$90.68
|
| Rate for Payer: Cash Price |
$159.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$149.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$89.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$113.97
|
| Rate for Payer: Medical Associates Commercial |
$149.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$89.78
|
| Rate for Payer: Midlands Choice Commercial |
$139.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$115.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$103.25
|
| Rate for Payer: United Healthcare Commercial |
$179.57
|
| Rate for Payer: United Healthcare Managed Medicare |
$117.72
|
|
|
tirofiban 50 mcg/mL 250ml SD Sol [VDMC]
|
Facility
|
OP
|
$505.30
|
|
|
Service Code
|
HCPCS J3246
|
| Hospital Charge Code |
11224748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$227.38 |
| Max. Negotiated Rate |
$454.77 |
| Rate for Payer: Aetna of IA Commercial |
$454.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$454.77
|
| Rate for Payer: Aetna of IA Medicare |
$288.02
|
| Rate for Payer: Amerigroup Medicaid |
$291.46
|
| Rate for Payer: Amerigroup Medicare |
$229.66
|
| Rate for Payer: Cash Price |
$404.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$378.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$227.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$288.63
|
| Rate for Payer: Medical Associates Commercial |
$378.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$227.38
|
| Rate for Payer: Midlands Choice Commercial |
$353.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$292.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$261.49
|
| Rate for Payer: United Healthcare Commercial |
$454.77
|
| Rate for Payer: United Healthcare Managed Medicare |
$298.13
|
|
|
tirofiban 50 mcg/mL 250ml SD Sol [VDMC]
|
Facility
|
IP
|
$505.30
|
|
|
Service Code
|
HCPCS J3246
|
| Hospital Charge Code |
11224748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$353.71 |
| Max. Negotiated Rate |
$454.77 |
| Rate for Payer: Aetna of IA Commercial |
$454.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$454.77
|
| Rate for Payer: Cash Price |
$404.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$378.98
|
| Rate for Payer: Medical Associates Commercial |
$378.98
|
| Rate for Payer: Midlands Choice Commercial |
$353.71
|
| Rate for Payer: United Healthcare Commercial |
$454.77
|
|
|
Tissue Transglutaminase IgA Ab DMCL
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
8037815
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna of IA Commercial |
$99.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$82.50
|
| Rate for Payer: Medical Associates Commercial |
$82.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.00
|
| Rate for Payer: United Healthcare Commercial |
$99.00
|
|
|
Tissue Transglutaminase IgA Ab DMCL
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
8037815
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna of IA Commercial |
$99.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.00
|
| Rate for Payer: Aetna of IA Medicare |
$62.70
|
| Rate for Payer: Amerigroup Medicaid |
$63.45
|
| Rate for Payer: Amerigroup Medicare |
$50.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$82.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.83
|
| Rate for Payer: Medical Associates Commercial |
$82.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.92
|
| Rate for Payer: United Healthcare Commercial |
$99.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$61.68
|
| Rate for Payer: Wellmark IA PPO |
$67.95
|
|
|
Tissue Transglutaminase IgG Ab DMCL
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
8037816
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna of IA Commercial |
$99.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$82.50
|
| Rate for Payer: Medical Associates Commercial |
$82.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.00
|
| Rate for Payer: United Healthcare Commercial |
$99.00
|
|
|
Tissue Transglutaminase IgG Ab DMCL
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
8037816
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna of IA Commercial |
$99.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.00
|
| Rate for Payer: Aetna of IA Medicare |
$62.70
|
| Rate for Payer: Amerigroup Medicaid |
$63.45
|
| Rate for Payer: Amerigroup Medicare |
$50.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$82.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.83
|
| Rate for Payer: Medical Associates Commercial |
$82.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.92
|
| Rate for Payer: United Healthcare Commercial |
$99.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$61.68
|
| Rate for Payer: Wellmark IA PPO |
$67.95
|
|
|
TIS TRNFR E/N/E/L 10 SQ CM/<
|
Facility
|
OP
|
$2,919.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
7982914
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,313.55 |
| Max. Negotiated Rate |
$3,434.06 |
| Rate for Payer: Aetna of IA Commercial |
$2,627.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,627.10
|
| Rate for Payer: Aetna of IA Medicare |
$1,663.83
|
| Rate for Payer: Amerigroup Medicaid |
$1,683.68
|
| Rate for Payer: Amerigroup Medicare |
$1,326.69
|
| Rate for Payer: Cash Price |
$2,335.20
|
| Rate for Payer: Cash Price |
$2,335.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,189.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,313.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,667.33
|
| Rate for Payer: Medical Associates Commercial |
$2,189.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,313.55
|
| Rate for Payer: Midlands Choice Commercial |
$2,043.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,691.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,510.58
|
| Rate for Payer: United Healthcare Commercial |
$2,627.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,722.21
|
| Rate for Payer: Wellmark IA HMO WHPI |
$3,117.47
|
| Rate for Payer: Wellmark IA PPO |
$3,434.06
|
|
|
TIS TRNFR E/N/E/L 10 SQ CM/<
|
Facility
|
IP
|
$2,919.00
|
|
|
Service Code
|
CPT 14060
|
| Hospital Charge Code |
7982914
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$2,627.10 |
| Rate for Payer: Aetna of IA Commercial |
$2,627.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,627.10
|
| Rate for Payer: Cash Price |
$2,335.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,189.25
|
| Rate for Payer: Medical Associates Commercial |
$2,189.25
|
| Rate for Payer: Midlands Choice Commercial |
$2,043.30
|
| Rate for Payer: United Healthcare Commercial |
$2,627.10
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
OP
|
$2,919.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
7982913
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,313.55 |
| Max. Negotiated Rate |
$3,434.06 |
| Rate for Payer: Aetna of IA Commercial |
$2,627.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,627.10
|
| Rate for Payer: Aetna of IA Medicare |
$1,663.83
|
| Rate for Payer: Amerigroup Medicaid |
$1,683.68
|
| Rate for Payer: Amerigroup Medicare |
$1,326.69
|
| Rate for Payer: Cash Price |
$2,335.20
|
| Rate for Payer: Cash Price |
$2,335.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,189.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,313.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,667.33
|
| Rate for Payer: Medical Associates Commercial |
$2,189.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,313.55
|
| Rate for Payer: Midlands Choice Commercial |
$2,043.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,691.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,510.58
|
| Rate for Payer: United Healthcare Commercial |
$2,627.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,722.21
|
| Rate for Payer: Wellmark IA HMO WHPI |
$3,117.47
|
| Rate for Payer: Wellmark IA PPO |
$3,434.06
|
|
|
TIS TRNFR F/C/C/M/N/A/G/H/F
|
Facility
|
IP
|
$2,919.00
|
|
|
Service Code
|
CPT 14040
|
| Hospital Charge Code |
7982913
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,043.30 |
| Max. Negotiated Rate |
$2,627.10 |
| Rate for Payer: Aetna of IA Commercial |
$2,627.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,627.10
|
| Rate for Payer: Cash Price |
$2,335.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,189.25
|
| Rate for Payer: Medical Associates Commercial |
$2,189.25
|
| Rate for Payer: Midlands Choice Commercial |
$2,043.30
|
| Rate for Payer: United Healthcare Commercial |
$2,627.10
|
|
|
tiZANidine 4 mg Tab [VDMC]
|
Facility
|
OP
|
$2.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Aetna of IA Commercial |
$2.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.23
|
| Rate for Payer: Aetna of IA Medicare |
$1.42
|
| Rate for Payer: Amerigroup Medicaid |
$1.43
|
| Rate for Payer: Amerigroup Medicare |
$1.13
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.86
|
| 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 |
$1.42
|
| Rate for Payer: Medical Associates Commercial |
$1.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.29
|
| Rate for Payer: United Healthcare Commercial |
$2.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.47
|
|
|
tiZANidine 4 mg Tab [VDMC]
|
Facility
|
IP
|
$2.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425290
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Aetna of IA Commercial |
$2.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.23
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.86
|
| Rate for Payer: Medical Associates Commercial |
$1.86
|
| Rate for Payer: Midlands Choice Commercial |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$2.23
|
|
|
tobramycin-dexamethasone Ophth 0.3%-0.1% Susp [VDMC]
|
Facility
|
OP
|
$142.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10381970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.31 |
| Max. Negotiated Rate |
$128.63 |
| Rate for Payer: Aetna of IA Commercial |
$128.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.63
|
| Rate for Payer: Aetna of IA Medicare |
$81.46
|
| Rate for Payer: Amerigroup Medicaid |
$82.44
|
| Rate for Payer: Amerigroup Medicare |
$64.96
|
| Rate for Payer: Cash Price |
$114.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.64
|
| Rate for Payer: Medical Associates Commercial |
$107.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.31
|
| Rate for Payer: Midlands Choice Commercial |
$100.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$73.96
|
| Rate for Payer: United Healthcare Commercial |
$128.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.32
|
|
|
tobramycin-dexamethasone Ophth 0.3%-0.1% Susp [VDMC]
|
Facility
|
IP
|
$142.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10381970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$100.04 |
| Max. Negotiated Rate |
$128.63 |
| Rate for Payer: Aetna of IA Commercial |
$128.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$128.63
|
| Rate for Payer: Cash Price |
$114.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.19
|
| Rate for Payer: Medical Associates Commercial |
$107.19
|
| Rate for Payer: Midlands Choice Commercial |
$100.04
|
| Rate for Payer: United Healthcare Commercial |
$128.63
|
|
|
Tobramycin Level Trough DMCL
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
CPT 80200
|
| Hospital Charge Code |
8037817
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$138.60 |
| Rate for Payer: Aetna of IA Commercial |
$138.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$138.60
|
| Rate for Payer: Aetna of IA Medicare |
$87.78
|
| Rate for Payer: Amerigroup Medicaid |
$88.83
|
| Rate for Payer: Amerigroup Medicare |
$69.99
|
| Rate for Payer: Cash Price |
$123.20
|
| Rate for Payer: Cash Price |
$123.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$115.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$69.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$87.96
|
| Rate for Payer: Medical Associates Commercial |
$115.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$69.30
|
| Rate for Payer: Midlands Choice Commercial |
$107.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$89.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$79.70
|
| Rate for Payer: United Healthcare Commercial |
$138.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$90.86
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
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 Ophth 0.3% 5 ml Sol [VDMC]
|
Facility
|
OP
|
$33.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10439585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$29.74 |
| Rate for Payer: Aetna of IA Commercial |
$29.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.74
|
| Rate for Payer: Aetna of IA Medicare |
$18.83
|
| Rate for Payer: Amerigroup Medicaid |
$19.06
|
| Rate for Payer: Amerigroup Medicare |
$15.02
|
| Rate for Payer: Cash Price |
$26.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.87
|
| Rate for Payer: Medical Associates Commercial |
$24.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.87
|
| Rate for Payer: Midlands Choice Commercial |
$23.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.10
|
| Rate for Payer: United Healthcare Commercial |
$29.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.49
|
|
|
tobramycin Ophth 0.3% 5 ml Sol [VDMC]
|
Facility
|
IP
|
$33.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10439585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.13 |
| Max. Negotiated Rate |
$29.74 |
| Rate for Payer: Aetna of IA Commercial |
$29.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.74
|
| Rate for Payer: Cash Price |
$26.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.78
|
| Rate for Payer: Medical Associates Commercial |
$24.78
|
| Rate for Payer: Midlands Choice Commercial |
$23.13
|
| Rate for Payer: United Healthcare Commercial |
$29.74
|
|
|
tolterodine 2 mg Tab [VDMC]
|
Facility
|
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
|
|
|
tolterodine 2 mg Tab [VDMC]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10425430
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of IA Commercial |
$1.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.70
|
| Rate for Payer: Aetna of IA Medicare |
$1.08
|
| Rate for Payer: Amerigroup Medicaid |
$1.09
|
| Rate for Payer: Amerigroup Medicare |
$0.86
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$1.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.12
|
|
|
topiramate 100 mg Tab [VDMC]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10430641
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Midlands Choice Commercial |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
|
