|
XR Wrist 2 Views Left
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
CPT 73100 LT
|
| Hospital Charge Code |
1170606
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of IA Commercial |
$114.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$114.30
|
| Rate for Payer: Aetna of IA Medicare |
$72.39
|
| Rate for Payer: Amerigroup Medicaid |
$73.25
|
| Rate for Payer: Amerigroup Medicare |
$57.72
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$95.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.54
|
| Rate for Payer: Medical Associates Commercial |
$95.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.15
|
| Rate for Payer: Midlands Choice Commercial |
$88.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$73.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$65.72
|
| Rate for Payer: United Healthcare Commercial |
$114.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$74.93
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Wrist 2 Views Right
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
CPT 73100 RT
|
| Hospital Charge Code |
1170608
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of IA Commercial |
$114.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$114.30
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$95.25
|
| Rate for Payer: Medical Associates Commercial |
$95.25
|
| Rate for Payer: Midlands Choice Commercial |
$88.90
|
| Rate for Payer: United Healthcare Commercial |
$114.30
|
|
|
XR Wrist 2 Views Right
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
CPT 73100 RT
|
| Hospital Charge Code |
1170608
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of IA Commercial |
$114.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$114.30
|
| Rate for Payer: Aetna of IA Medicare |
$72.39
|
| Rate for Payer: Amerigroup Medicaid |
$73.25
|
| Rate for Payer: Amerigroup Medicare |
$57.72
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$95.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.54
|
| Rate for Payer: Medical Associates Commercial |
$95.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.15
|
| Rate for Payer: Midlands Choice Commercial |
$88.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$73.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$65.72
|
| Rate for Payer: United Healthcare Commercial |
$114.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$74.93
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Wrist Complete Left
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 73110 LT
|
| Hospital Charge Code |
1170612
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
XR Wrist Complete Left
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 73110 LT
|
| Hospital Charge Code |
1170612
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$84.21
|
| Rate for Payer: Amerigroup Medicare |
$66.36
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$65.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$83.40
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.70
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$84.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$75.56
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Wrist Complete Right
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 73110 RT
|
| Hospital Charge Code |
1170614
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
XR Wrist Complete Right
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 73110 RT
|
| Hospital Charge Code |
1170614
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$84.21
|
| Rate for Payer: Amerigroup Medicare |
$66.36
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$65.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$83.40
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.70
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$84.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$75.56
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
Zinc Level DMCL
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
CPT 84630
|
| Hospital Charge Code |
8519183
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of IA Commercial |
$55.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.80
|
| Rate for Payer: Aetna of IA Medicare |
$35.34
|
| Rate for Payer: Amerigroup Medicaid |
$35.76
|
| Rate for Payer: Amerigroup Medicare |
$28.18
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.41
|
| Rate for Payer: Medical Associates Commercial |
$46.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.90
|
| Rate for Payer: Midlands Choice Commercial |
$43.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.08
|
| Rate for Payer: United Healthcare Commercial |
$55.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.58
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
Zinc Level DMCL
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
CPT 84630
|
| Hospital Charge Code |
8519183
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of IA Commercial |
$55.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.80
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.50
|
| Rate for Payer: Medical Associates Commercial |
$46.50
|
| Rate for Payer: Midlands Choice Commercial |
$43.40
|
| Rate for Payer: United Healthcare Commercial |
$55.80
|
|
|
zinc oxide Top 40% Paste [VDMC]
|
Facility
|
OP
|
$35.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
22876909
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.16 |
| Max. Negotiated Rate |
$32.33 |
| Rate for Payer: Aetna of IA Commercial |
$32.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.33
|
| Rate for Payer: Aetna of IA Medicare |
$20.47
|
| Rate for Payer: Amerigroup Medicaid |
$20.72
|
| Rate for Payer: Amerigroup Medicare |
$16.33
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$16.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.52
|
| Rate for Payer: Medical Associates Commercial |
$26.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.16
|
| Rate for Payer: Midlands Choice Commercial |
$25.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.59
|
| Rate for Payer: United Healthcare Commercial |
$32.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$21.19
|
|
|
zinc oxide Top 40% Paste [VDMC]
|
Facility
|
IP
|
$35.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
22876909
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.14 |
| Max. Negotiated Rate |
$32.33 |
| Rate for Payer: Aetna of IA Commercial |
$32.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.33
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.94
|
| Rate for Payer: Medical Associates Commercial |
$26.94
|
| Rate for Payer: Midlands Choice Commercial |
$25.14
|
| Rate for Payer: United Healthcare Commercial |
$32.33
|
|
|
zinc sulfate 50 mg Cap [VDMC]
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10428828
|
|
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
|
|
|
zinc sulfate 50 mg Cap [VDMC]
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10428828
|
|
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
|
|
|
ZioPatch EXT ECG>48HR<7D RECORDING
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 93242
|
| Hospital Charge Code |
8831646
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$137.25 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of IA Commercial |
$274.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$274.50
|
| Rate for Payer: Aetna of IA Medicare |
$173.85
|
| Rate for Payer: Amerigroup Medicaid |
$175.92
|
| Rate for Payer: Amerigroup Medicare |
$138.62
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$137.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$174.22
|
| Rate for Payer: Medical Associates Commercial |
$228.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$137.25
|
| Rate for Payer: Midlands Choice Commercial |
$213.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$176.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$157.84
|
| Rate for Payer: United Healthcare Commercial |
$274.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$179.95
|
| Rate for Payer: Wellmark IA HMO WHPI |
$183.63
|
| Rate for Payer: Wellmark IA PPO |
$202.28
|
|
|
ZioPatch EXT ECG>48HR<7D RECORDING
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 93242
|
| Hospital Charge Code |
8831646
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of IA Commercial |
$274.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$274.50
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.75
|
| Rate for Payer: Medical Associates Commercial |
$228.75
|
| Rate for Payer: Midlands Choice Commercial |
$213.50
|
| Rate for Payer: United Healthcare Commercial |
$274.50
|
|
|
ZioPatch EXT ECG>7D<15D RECORDING
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
CPT 93246
|
| Hospital Charge Code |
8829640
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of IA Commercial |
$274.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$274.50
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.75
|
| Rate for Payer: Medical Associates Commercial |
$228.75
|
| Rate for Payer: Midlands Choice Commercial |
$213.50
|
| Rate for Payer: United Healthcare Commercial |
$274.50
|
|
|
ZioPatch EXT ECG>7D<15D RECORDING
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
CPT 93246
|
| Hospital Charge Code |
8829640
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$137.25 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of IA Commercial |
$274.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$274.50
|
| Rate for Payer: Aetna of IA Medicare |
$173.85
|
| Rate for Payer: Amerigroup Medicaid |
$175.92
|
| Rate for Payer: Amerigroup Medicare |
$138.62
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$228.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$137.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$174.22
|
| Rate for Payer: Medical Associates Commercial |
$228.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$137.25
|
| Rate for Payer: Midlands Choice Commercial |
$213.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$176.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$157.84
|
| Rate for Payer: United Healthcare Commercial |
$274.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$179.95
|
| Rate for Payer: Wellmark IA HMO WHPI |
$183.63
|
| Rate for Payer: Wellmark IA PPO |
$202.28
|
|
|
ziprasidone 20 mg Cap [VDMC]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10608440
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of IA Commercial |
$2.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.21
|
| Rate for Payer: Aetna of IA Medicare |
$1.40
|
| Rate for Payer: Amerigroup Medicaid |
$1.42
|
| Rate for Payer: Amerigroup Medicare |
$1.12
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.11
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.41
|
| Rate for Payer: Medical Associates Commercial |
$1.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.11
|
| Rate for Payer: Midlands Choice Commercial |
$1.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.27
|
| Rate for Payer: United Healthcare Commercial |
$2.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.45
|
|
|
ziprasidone 20 mg Cap [VDMC]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10608440
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of IA Commercial |
$2.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.21
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.84
|
| Rate for Payer: Medical Associates Commercial |
$1.84
|
| Rate for Payer: Midlands Choice Commercial |
$1.72
|
| Rate for Payer: United Healthcare Commercial |
$2.21
|
|
|
ziprasidone 20 mg/ml IM SDV Inj [VDMC]
|
Facility
|
IP
|
$147.62
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
10428897
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$103.33 |
| Max. Negotiated Rate |
$132.86 |
| Rate for Payer: Aetna of IA Commercial |
$132.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$132.86
|
| Rate for Payer: Cash Price |
$118.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$110.72
|
| Rate for Payer: Medical Associates Commercial |
$110.72
|
| Rate for Payer: Midlands Choice Commercial |
$103.33
|
| Rate for Payer: United Healthcare Commercial |
$132.86
|
|
|
ziprasidone 20 mg/ml IM SDV Inj [VDMC]
|
Facility
|
OP
|
$147.62
|
|
|
Service Code
|
HCPCS J3486
|
| Hospital Charge Code |
10428897
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$66.43 |
| Max. Negotiated Rate |
$132.86 |
| Rate for Payer: Aetna of IA Commercial |
$132.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$132.86
|
| Rate for Payer: Aetna of IA Medicare |
$84.14
|
| Rate for Payer: Amerigroup Medicaid |
$85.15
|
| Rate for Payer: Amerigroup Medicare |
$67.09
|
| Rate for Payer: Cash Price |
$118.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$110.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$66.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$84.32
|
| Rate for Payer: Medical Associates Commercial |
$110.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$66.43
|
| Rate for Payer: Midlands Choice Commercial |
$103.33
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$85.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$76.39
|
| Rate for Payer: United Healthcare Commercial |
$132.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$87.10
|
|
|
zoledronic acid 4mg/5ml SDV 5 ml [VDMC]
|
Facility
|
IP
|
$184.32
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
10428966
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$129.02 |
| Max. Negotiated Rate |
$165.89 |
| Rate for Payer: Aetna of IA Commercial |
$165.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$165.89
|
| Rate for Payer: Cash Price |
$147.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$138.24
|
| Rate for Payer: Medical Associates Commercial |
$138.24
|
| Rate for Payer: Midlands Choice Commercial |
$129.02
|
| Rate for Payer: United Healthcare Commercial |
$165.89
|
|
|
zoledronic acid 4mg/5ml SDV 5 ml [VDMC]
|
Facility
|
OP
|
$184.32
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
10428966
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$82.94 |
| Max. Negotiated Rate |
$165.89 |
| Rate for Payer: Aetna of IA Commercial |
$165.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$165.89
|
| Rate for Payer: Aetna of IA Medicare |
$105.06
|
| Rate for Payer: Amerigroup Medicaid |
$106.32
|
| Rate for Payer: Amerigroup Medicare |
$83.77
|
| Rate for Payer: Cash Price |
$147.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$138.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$82.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$105.28
|
| Rate for Payer: Medical Associates Commercial |
$138.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$82.94
|
| Rate for Payer: Midlands Choice Commercial |
$129.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$106.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$95.39
|
| Rate for Payer: United Healthcare Commercial |
$165.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$108.75
|
|
|
zoledronic acid 5 mg/100 mL SD PREMIX [VDMC]
|
Facility
|
IP
|
$290.92
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
11224002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$203.64 |
| Max. Negotiated Rate |
$261.83 |
| Rate for Payer: Aetna of IA Commercial |
$261.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$261.83
|
| Rate for Payer: Cash Price |
$232.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$218.19
|
| Rate for Payer: Medical Associates Commercial |
$218.19
|
| Rate for Payer: Midlands Choice Commercial |
$203.64
|
| Rate for Payer: United Healthcare Commercial |
$261.83
|
|
|
zoledronic acid 5 mg/100 mL SD PREMIX [VDMC]
|
Facility
|
OP
|
$290.92
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
11224002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$130.91 |
| Max. Negotiated Rate |
$261.83 |
| Rate for Payer: Aetna of IA Commercial |
$261.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$261.83
|
| Rate for Payer: Aetna of IA Medicare |
$165.82
|
| Rate for Payer: Amerigroup Medicaid |
$167.80
|
| Rate for Payer: Amerigroup Medicare |
$132.22
|
| Rate for Payer: Cash Price |
$232.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$218.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$130.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$166.17
|
| Rate for Payer: Medical Associates Commercial |
$218.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$130.91
|
| Rate for Payer: Midlands Choice Commercial |
$203.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$168.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$150.55
|
| Rate for Payer: United Healthcare Commercial |
$261.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$171.64
|
|
