|
Valproic Acid Level DMCL
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 80164
|
| Hospital Charge Code |
8037821
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
|
|
valsartan 160 mg Tab [VDMC]
|
Facility
|
IP
|
$1.90
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10427245
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Aetna of IA Commercial |
$1.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.71
|
| Rate for Payer: Cash Price |
$1.52
|
| 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 |
$1.33
|
| Rate for Payer: United Healthcare Commercial |
$1.71
|
|
|
valsartan 160 mg Tab [VDMC]
|
Facility
|
OP
|
$1.90
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10427245
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Aetna of IA Commercial |
$1.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.71
|
| 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 |
$1.52
|
| 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 |
$1.33
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.71
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.12
|
|
|
valsartan 40 mg Tab [VDMC]
|
Facility
|
IP
|
$1.71
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10427314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna of IA Commercial |
$1.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.54
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.28
|
| Rate for Payer: Medical Associates Commercial |
$1.28
|
| Rate for Payer: Midlands Choice Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
|
|
valsartan 40 mg Tab [VDMC]
|
Facility
|
OP
|
$1.71
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10427314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna of IA Commercial |
$1.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.54
|
| Rate for Payer: Aetna of IA Medicare |
$0.97
|
| Rate for Payer: Amerigroup Medicaid |
$0.99
|
| Rate for Payer: Amerigroup Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.98
|
| Rate for Payer: Medical Associates Commercial |
$1.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.77
|
| Rate for Payer: Midlands Choice Commercial |
$1.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.01
|
|
|
vancomycin 125 mg Cap [VDMC]
|
Facility
|
IP
|
$10.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10427521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$9.18 |
| Rate for Payer: Aetna of IA Commercial |
$9.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.18
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.65
|
| Rate for Payer: Medical Associates Commercial |
$7.65
|
| Rate for Payer: Midlands Choice Commercial |
$7.14
|
| Rate for Payer: United Healthcare Commercial |
$9.18
|
|
|
vancomycin 125 mg Cap [VDMC]
|
Facility
|
OP
|
$10.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10427521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$9.18 |
| Rate for Payer: Aetna of IA Commercial |
$9.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.18
|
| Rate for Payer: Aetna of IA Medicare |
$5.81
|
| Rate for Payer: Amerigroup Medicaid |
$5.88
|
| Rate for Payer: Amerigroup Medicare |
$4.63
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.65
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.83
|
| Rate for Payer: Medical Associates Commercial |
$7.65
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.59
|
| Rate for Payer: Midlands Choice Commercial |
$7.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.28
|
| Rate for Payer: United Healthcare Commercial |
$9.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.02
|
|
|
vancomycin 1 g IV SDV Inj [VDMC]
|
Facility
|
OP
|
$27.11
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
10427452
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.20 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$24.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.40
|
| Rate for Payer: Aetna of IA Medicare |
$15.45
|
| Rate for Payer: Amerigroup Medicaid |
$15.64
|
| Rate for Payer: Amerigroup Medicare |
$12.32
|
| Rate for Payer: Cash Price |
$21.69
|
| Rate for Payer: Cash Price |
$21.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.48
|
| Rate for Payer: Medical Associates Commercial |
$20.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.20
|
| Rate for Payer: Midlands Choice Commercial |
$18.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.03
|
| Rate for Payer: United Healthcare Commercial |
$24.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.99
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
vancomycin 1 g IV SDV Inj [VDMC]
|
Facility
|
IP
|
$27.11
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
10427452
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$24.40 |
| Rate for Payer: Aetna of IA Commercial |
$24.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.40
|
| Rate for Payer: Cash Price |
$21.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.33
|
| Rate for Payer: Medical Associates Commercial |
$20.33
|
| Rate for Payer: Midlands Choice Commercial |
$18.98
|
| Rate for Payer: United Healthcare Commercial |
$24.40
|
|
|
vancomycin 250 mg Cap [VDMC]
|
Facility
|
IP
|
$6.83
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10427590
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna of IA Commercial |
$6.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.15
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.13
|
| Rate for Payer: Medical Associates Commercial |
$5.13
|
| Rate for Payer: Midlands Choice Commercial |
$4.78
|
| Rate for Payer: United Healthcare Commercial |
$6.15
|
|
|
vancomycin 250 mg Cap [VDMC]
|
Facility
|
OP
|
$6.83
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10427590
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna of IA Commercial |
$6.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.15
|
| Rate for Payer: Aetna of IA Medicare |
$3.90
|
| Rate for Payer: Amerigroup Medicaid |
$3.94
|
| Rate for Payer: Amerigroup Medicare |
$3.11
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.13
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.90
|
| Rate for Payer: Medical Associates Commercial |
$5.13
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.08
|
| Rate for Payer: Midlands Choice Commercial |
$4.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.54
|
| Rate for Payer: United Healthcare Commercial |
$6.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.03
|
|
|
Vancomycin HCL 1.25 gm/250 ml IV [VDMC]
|
Facility
|
IP
|
$110.93
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23484344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$77.65 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna of IA Commercial |
$99.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.84
|
| Rate for Payer: Cash Price |
$88.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.20
|
| Rate for Payer: Medical Associates Commercial |
$83.20
|
| Rate for Payer: Midlands Choice Commercial |
$77.65
|
| Rate for Payer: United Healthcare Commercial |
$99.84
|
|
|
Vancomycin HCL 1.25 gm/250 ml IV [VDMC]
|
Facility
|
OP
|
$110.93
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23484344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.92 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$99.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.84
|
| Rate for Payer: Aetna of IA Medicare |
$63.23
|
| Rate for Payer: Amerigroup Medicaid |
$63.98
|
| Rate for Payer: Amerigroup Medicare |
$50.42
|
| Rate for Payer: Cash Price |
$88.74
|
| Rate for Payer: Cash Price |
$88.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$63.36
|
| Rate for Payer: Medical Associates Commercial |
$83.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.92
|
| Rate for Payer: Midlands Choice Commercial |
$77.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$64.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.41
|
| Rate for Payer: United Healthcare Commercial |
$99.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.45
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
vancomycin HCL1.5 gm/300ml IV [VDMC]
|
Facility
|
OP
|
$123.13
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23484625
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.41 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$110.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$110.82
|
| Rate for Payer: Aetna of IA Medicare |
$70.18
|
| Rate for Payer: Amerigroup Medicaid |
$71.02
|
| Rate for Payer: Amerigroup Medicare |
$55.96
|
| Rate for Payer: Cash Price |
$98.50
|
| Rate for Payer: Cash Price |
$98.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$92.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$70.33
|
| Rate for Payer: Medical Associates Commercial |
$92.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.41
|
| Rate for Payer: Midlands Choice Commercial |
$86.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$71.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.72
|
| Rate for Payer: United Healthcare Commercial |
$110.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$72.65
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
vancomycin HCL1.5 gm/300ml IV [VDMC]
|
Facility
|
IP
|
$123.13
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23484625
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.19 |
| Max. Negotiated Rate |
$110.82 |
| Rate for Payer: Aetna of IA Commercial |
$110.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$110.82
|
| Rate for Payer: Cash Price |
$98.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$92.35
|
| Rate for Payer: Medical Associates Commercial |
$92.35
|
| Rate for Payer: Midlands Choice Commercial |
$86.19
|
| Rate for Payer: United Healthcare Commercial |
$110.82
|
|
|
Vancomycin HCL 1.75 gm/350ml IV [VDMC]
|
Facility
|
IP
|
$135.30
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23484904
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$94.71 |
| Max. Negotiated Rate |
$121.77 |
| Rate for Payer: Aetna of IA Commercial |
$121.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.77
|
| Rate for Payer: Cash Price |
$108.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$101.48
|
| Rate for Payer: Medical Associates Commercial |
$101.48
|
| Rate for Payer: Midlands Choice Commercial |
$94.71
|
| Rate for Payer: United Healthcare Commercial |
$121.77
|
|
|
Vancomycin HCL 1.75 gm/350ml IV [VDMC]
|
Facility
|
OP
|
$135.30
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23484904
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.89 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$121.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.77
|
| Rate for Payer: Aetna of IA Medicare |
$77.12
|
| Rate for Payer: Amerigroup Medicaid |
$78.04
|
| Rate for Payer: Amerigroup Medicare |
$61.49
|
| Rate for Payer: Cash Price |
$108.24
|
| Rate for Payer: Cash Price |
$108.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$101.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$60.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$77.28
|
| Rate for Payer: Medical Associates Commercial |
$101.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$60.89
|
| Rate for Payer: Midlands Choice Commercial |
$94.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$78.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$70.02
|
| Rate for Payer: United Healthcare Commercial |
$121.77
|
| Rate for Payer: United Healthcare Managed Medicare |
$79.83
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
Vancomycin HCL 1gm/200ml IV [VDMC]
|
Facility
|
OP
|
$98.75
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23192247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.44 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$88.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.88
|
| Rate for Payer: Aetna of IA Medicare |
$56.29
|
| Rate for Payer: Amerigroup Medicaid |
$56.96
|
| Rate for Payer: Amerigroup Medicare |
$44.88
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$44.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.41
|
| Rate for Payer: Medical Associates Commercial |
$74.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$44.44
|
| Rate for Payer: Midlands Choice Commercial |
$69.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$51.10
|
| Rate for Payer: United Healthcare Commercial |
$88.88
|
| Rate for Payer: United Healthcare Managed Medicare |
$58.26
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
Vancomycin HCL 1gm/200ml IV [VDMC]
|
Facility
|
IP
|
$98.75
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23192247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$69.13 |
| Max. Negotiated Rate |
$88.88 |
| Rate for Payer: Aetna of IA Commercial |
$88.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.88
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.06
|
| Rate for Payer: Medical Associates Commercial |
$74.06
|
| Rate for Payer: Midlands Choice Commercial |
$69.13
|
| Rate for Payer: United Healthcare Commercial |
$88.88
|
|
|
Vancomycin HCL 750mg/150ml IV [VDMC]
|
Facility
|
IP
|
$86.56
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23609821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.59 |
| Max. Negotiated Rate |
$77.91 |
| Rate for Payer: Aetna of IA Commercial |
$77.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$77.91
|
| Rate for Payer: Cash Price |
$69.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$64.92
|
| Rate for Payer: Medical Associates Commercial |
$64.92
|
| Rate for Payer: Midlands Choice Commercial |
$60.59
|
| Rate for Payer: United Healthcare Commercial |
$77.91
|
|
|
Vancomycin HCL 750mg/150ml IV [VDMC]
|
Facility
|
OP
|
$86.56
|
|
|
Service Code
|
HCPCS J3372
|
| Hospital Charge Code |
23609821
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.95 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$77.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$77.91
|
| Rate for Payer: Aetna of IA Medicare |
$49.34
|
| Rate for Payer: Amerigroup Medicaid |
$49.93
|
| Rate for Payer: Amerigroup Medicare |
$39.34
|
| Rate for Payer: Cash Price |
$69.25
|
| Rate for Payer: Cash Price |
$69.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$64.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$38.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$49.45
|
| Rate for Payer: Medical Associates Commercial |
$64.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$38.95
|
| Rate for Payer: Midlands Choice Commercial |
$60.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$50.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$44.80
|
| Rate for Payer: United Healthcare Commercial |
$77.91
|
| Rate for Payer: United Healthcare Managed Medicare |
$51.07
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
VANCOMYCIN LEVEL
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
1634896
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
|
|
VANCOMYCIN LEVEL
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
1634896
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Aetna of IA Medicare |
$73.53
|
| Rate for Payer: Amerigroup Medicaid |
$74.41
|
| Rate for Payer: Amerigroup Medicare |
$58.63
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.68
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.05
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$66.76
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
VANCOMYCIN LEVEL
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
1634897
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Aetna of IA Medicare |
$73.53
|
| Rate for Payer: Amerigroup Medicaid |
$74.41
|
| Rate for Payer: Amerigroup Medicare |
$58.63
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.68
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.05
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$66.76
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
VANCOMYCIN LEVEL
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
1634897
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$116.10 |
| Rate for Payer: Aetna of IA Commercial |
$116.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
| Rate for Payer: Medical Associates Commercial |
$96.75
|
| Rate for Payer: Midlands Choice Commercial |
$90.30
|
| Rate for Payer: United Healthcare Commercial |
$116.10
|
|
