|
Calcium Urine Timed DMCL
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
CPT 82340
|
| Hospital Charge Code |
8037507
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
|
|
calcium-vitamin D 500 mg-200 intl units Tab [VDMC]
|
Facility
|
OP
|
$1.14
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10373240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Aetna of IA Medicare |
$0.65
|
| Rate for Payer: Amerigroup Medicaid |
$0.65
|
| Rate for Payer: Amerigroup Medicare |
$0.52
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.51
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.59
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.67
|
|
|
calcium-vitamin D 500 mg-200 intl units Tab [VDMC]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10373240
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
|
|
CANALITH REPOSITIONING PROC
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
CPT 95992 GP
|
| Hospital Charge Code |
6344980
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$104.40 |
| Rate for Payer: Aetna of IA Commercial |
$104.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$104.40
|
| Rate for Payer: Cash Price |
$92.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$87.00
|
| Rate for Payer: Medical Associates Commercial |
$87.00
|
| Rate for Payer: Midlands Choice Commercial |
$81.20
|
| Rate for Payer: United Healthcare Commercial |
$104.40
|
|
|
CANALITH REPOSITIONING PROC
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
CPT 95992 GP
|
| Hospital Charge Code |
6344980
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$52.20 |
| Max. Negotiated Rate |
$104.40 |
| Rate for Payer: Aetna of IA Commercial |
$104.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$104.40
|
| Rate for Payer: Aetna of IA Medicare |
$66.12
|
| Rate for Payer: Amerigroup Medicaid |
$66.91
|
| Rate for Payer: Amerigroup Medicare |
$52.72
|
| Rate for Payer: Cash Price |
$92.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$87.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$52.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$66.26
|
| Rate for Payer: Medical Associates Commercial |
$87.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$52.20
|
| Rate for Payer: Midlands Choice Commercial |
$81.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$67.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$60.03
|
| Rate for Payer: United Healthcare Commercial |
$104.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$68.44
|
|
|
CANNULATED SCREW
|
Facility
|
IP
|
$171.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8767789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$119.70 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna of IA Commercial |
$153.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.90
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$128.25
|
| Rate for Payer: Medical Associates Commercial |
$128.25
|
| Rate for Payer: Midlands Choice Commercial |
$119.70
|
| Rate for Payer: United Healthcare Commercial |
$153.90
|
|
|
CANNULATED SCREW
|
Facility
|
OP
|
$171.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8767789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna of IA Commercial |
$153.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.90
|
| Rate for Payer: Aetna of IA Medicare |
$97.47
|
| Rate for Payer: Amerigroup Medicaid |
$98.63
|
| Rate for Payer: Amerigroup Medicare |
$77.72
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$128.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$76.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$97.68
|
| Rate for Payer: Medical Associates Commercial |
$128.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$76.95
|
| Rate for Payer: Midlands Choice Commercial |
$119.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$99.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$88.49
|
| Rate for Payer: United Healthcare Commercial |
$153.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.89
|
|
|
capsaicin topical 0.1% Cream 42.5gm [VDMC]
|
Facility
|
IP
|
$42.80
|
|
|
Service Code
|
NDC 41167-0751-42
|
| Hospital Charge Code |
18835897
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.96 |
| Max. Negotiated Rate |
$38.52 |
| Rate for Payer: Aetna of IA Commercial |
$38.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.52
|
| Rate for Payer: Cash Price |
$34.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.10
|
| Rate for Payer: Medical Associates Commercial |
$32.10
|
| Rate for Payer: Midlands Choice Commercial |
$29.96
|
| Rate for Payer: United Healthcare Commercial |
$38.52
|
|
|
capsaicin topical 0.1% Cream 42.5gm [VDMC]
|
Facility
|
OP
|
$42.80
|
|
|
Service Code
|
NDC 41167-0751-42
|
| Hospital Charge Code |
18835897
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$38.52 |
| Rate for Payer: Aetna of IA Commercial |
$38.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.52
|
| Rate for Payer: Aetna of IA Medicare |
$24.40
|
| Rate for Payer: Amerigroup Medicaid |
$24.69
|
| Rate for Payer: Amerigroup Medicare |
$19.45
|
| Rate for Payer: Cash Price |
$34.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.45
|
| Rate for Payer: Medical Associates Commercial |
$32.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.26
|
| Rate for Payer: Midlands Choice Commercial |
$29.96
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.15
|
| Rate for Payer: United Healthcare Commercial |
$38.52
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.25
|
|
|
capsaicin topical 8% Kit [VDMC] 1 patch(es)
|
Facility
|
IP
|
$1,868.80
|
|
|
Service Code
|
HCPCS J7336
|
| Hospital Charge Code |
27617485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,308.16 |
| Max. Negotiated Rate |
$1,681.92 |
| Rate for Payer: Aetna of IA Commercial |
$1,681.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,681.92
|
| Rate for Payer: Cash Price |
$1,495.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,401.60
|
| Rate for Payer: Medical Associates Commercial |
$1,401.60
|
| Rate for Payer: Midlands Choice Commercial |
$1,308.16
|
| Rate for Payer: United Healthcare Commercial |
$1,681.92
|
|
|
capsaicin topical 8% Kit [VDMC] 1 patch(es)
|
Facility
|
OP
|
$1,868.80
|
|
|
Service Code
|
HCPCS J7336
|
| Hospital Charge Code |
27617485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$840.96 |
| Max. Negotiated Rate |
$1,681.92 |
| Rate for Payer: Aetna of IA Commercial |
$1,681.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,681.92
|
| Rate for Payer: Aetna of IA Medicare |
$1,065.22
|
| Rate for Payer: Amerigroup Medicaid |
$1,077.92
|
| Rate for Payer: Amerigroup Medicare |
$849.37
|
| Rate for Payer: Cash Price |
$1,495.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,401.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$840.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,067.46
|
| Rate for Payer: Medical Associates Commercial |
$1,401.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$840.96
|
| Rate for Payer: Midlands Choice Commercial |
$1,308.16
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,083.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$967.10
|
| Rate for Payer: United Healthcare Commercial |
$1,681.92
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,102.59
|
|
|
capsaicin topical 8% Kit [VDMC] 2 patch(es)
|
Facility
|
IP
|
$3,637.60
|
|
|
Service Code
|
HCPCS J7336
|
| Hospital Charge Code |
27617601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,546.32 |
| Max. Negotiated Rate |
$3,273.84 |
| Rate for Payer: Aetna of IA Commercial |
$3,273.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,273.84
|
| Rate for Payer: Cash Price |
$2,910.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,728.20
|
| Rate for Payer: Medical Associates Commercial |
$2,728.20
|
| Rate for Payer: Midlands Choice Commercial |
$2,546.32
|
| Rate for Payer: United Healthcare Commercial |
$3,273.84
|
|
|
capsaicin topical 8% Kit [VDMC] 2 patch(es)
|
Facility
|
OP
|
$3,637.60
|
|
|
Service Code
|
HCPCS J7336
|
| Hospital Charge Code |
27617601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,636.92 |
| Max. Negotiated Rate |
$3,273.84 |
| Rate for Payer: Aetna of IA Commercial |
$3,273.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,273.84
|
| Rate for Payer: Aetna of IA Medicare |
$2,073.43
|
| Rate for Payer: Amerigroup Medicaid |
$2,098.17
|
| Rate for Payer: Amerigroup Medicare |
$1,653.29
|
| Rate for Payer: Cash Price |
$2,910.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,728.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,636.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,077.80
|
| Rate for Payer: Medical Associates Commercial |
$2,728.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,636.92
|
| Rate for Payer: Midlands Choice Commercial |
$2,546.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,108.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,882.46
|
| Rate for Payer: United Healthcare Commercial |
$3,273.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,146.18
|
|
|
capsaicin topical 8% Kit [VDMC] 4 patch(es)
|
Facility
|
OP
|
$7,281.32
|
|
|
Service Code
|
HCPCS J7336
|
| Hospital Charge Code |
26706652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,276.59 |
| Max. Negotiated Rate |
$6,553.19 |
| Rate for Payer: Aetna of IA Commercial |
$6,553.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6,553.19
|
| Rate for Payer: Aetna of IA Medicare |
$4,150.35
|
| Rate for Payer: Amerigroup Medicaid |
$4,199.87
|
| Rate for Payer: Amerigroup Medicare |
$3,309.36
|
| Rate for Payer: Cash Price |
$5,825.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5,460.99
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,276.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,159.09
|
| Rate for Payer: Medical Associates Commercial |
$5,460.99
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,276.59
|
| Rate for Payer: Midlands Choice Commercial |
$5,096.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,220.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,768.08
|
| Rate for Payer: United Healthcare Commercial |
$6,553.19
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,295.98
|
|
|
capsaicin topical 8% Kit [VDMC] 4 patch(es)
|
Facility
|
IP
|
$7,281.32
|
|
|
Service Code
|
HCPCS J7336
|
| Hospital Charge Code |
26706652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,096.92 |
| Max. Negotiated Rate |
$6,553.19 |
| Rate for Payer: Aetna of IA Commercial |
$6,553.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6,553.19
|
| Rate for Payer: Cash Price |
$5,825.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5,460.99
|
| Rate for Payer: Medical Associates Commercial |
$5,460.99
|
| Rate for Payer: Midlands Choice Commercial |
$5,096.92
|
| Rate for Payer: United Healthcare Commercial |
$6,553.19
|
|
|
CAPSURE 30 SHOT
|
Facility
|
OP
|
$1,017.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8417550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$457.65 |
| Max. Negotiated Rate |
$915.30 |
| Rate for Payer: Aetna of IA Commercial |
$915.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$915.30
|
| Rate for Payer: Aetna of IA Medicare |
$579.69
|
| Rate for Payer: Amerigroup Medicaid |
$586.61
|
| Rate for Payer: Amerigroup Medicare |
$462.23
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$762.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$457.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$580.91
|
| Rate for Payer: Medical Associates Commercial |
$762.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$457.65
|
| Rate for Payer: Midlands Choice Commercial |
$711.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$589.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$526.30
|
| Rate for Payer: United Healthcare Commercial |
$915.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$600.03
|
|
|
CAPSURE 30 SHOT
|
Facility
|
IP
|
$1,017.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8417550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$711.90 |
| Max. Negotiated Rate |
$915.30 |
| Rate for Payer: Aetna of IA Commercial |
$915.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$915.30
|
| Rate for Payer: Cash Price |
$813.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$762.75
|
| Rate for Payer: Medical Associates Commercial |
$762.75
|
| Rate for Payer: Midlands Choice Commercial |
$711.90
|
| Rate for Payer: United Healthcare Commercial |
$915.30
|
|
|
carbachol Ophth 0.01% Sol 1.5ml [VDMC]
|
Facility
|
IP
|
$73.50
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11558009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$51.45 |
| Max. Negotiated Rate |
$66.15 |
| Rate for Payer: Aetna of IA Commercial |
$66.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$66.15
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$55.12
|
| Rate for Payer: Medical Associates Commercial |
$55.12
|
| Rate for Payer: Midlands Choice Commercial |
$51.45
|
| Rate for Payer: United Healthcare Commercial |
$66.15
|
|
|
carbachol Ophth 0.01% Sol 1.5ml [VDMC]
|
Facility
|
OP
|
$73.50
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11558009
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.08 |
| Max. Negotiated Rate |
$66.15 |
| Rate for Payer: Aetna of IA Commercial |
$66.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$66.15
|
| Rate for Payer: Aetna of IA Medicare |
$41.90
|
| Rate for Payer: Amerigroup Medicaid |
$42.39
|
| Rate for Payer: Amerigroup Medicare |
$33.41
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$55.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$33.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$41.98
|
| Rate for Payer: Medical Associates Commercial |
$55.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.08
|
| Rate for Payer: Midlands Choice Commercial |
$51.45
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$42.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$38.04
|
| Rate for Payer: United Healthcare Commercial |
$66.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$43.37
|
|
|
carBAMazepine 100 mg ER Tab [VDMC]
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10373786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna of IA Commercial |
$1.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.74
|
| Rate for Payer: Aetna of IA Medicare |
$1.10
|
| Rate for Payer: Amerigroup Medicaid |
$1.11
|
| Rate for Payer: Amerigroup Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.45
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.10
|
| Rate for Payer: Medical Associates Commercial |
$1.45
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.87
|
| Rate for Payer: Midlands Choice Commercial |
$1.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.14
|
|
|
carBAMazepine 100 mg ER Tab [VDMC]
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10373786
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna of IA Commercial |
$1.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.74
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.45
|
| Rate for Payer: Medical Associates Commercial |
$1.45
|
| Rate for Payer: Midlands Choice Commercial |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
|
|
carBAMazepine 200 mg ER Tab [VDMC]
|
Facility
|
OP
|
$11.68
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10373855
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: Aetna of IA Commercial |
$10.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.51
|
| Rate for Payer: Aetna of IA Medicare |
$6.66
|
| Rate for Payer: Amerigroup Medicaid |
$6.74
|
| Rate for Payer: Amerigroup Medicare |
$5.31
|
| Rate for Payer: Cash Price |
$9.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.76
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.67
|
| Rate for Payer: Medical Associates Commercial |
$8.76
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.26
|
| Rate for Payer: Midlands Choice Commercial |
$8.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.05
|
| Rate for Payer: United Healthcare Commercial |
$10.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.89
|
|
|
carBAMazepine 200 mg ER Tab [VDMC]
|
Facility
|
IP
|
$11.68
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10373855
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: Aetna of IA Commercial |
$10.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.51
|
| Rate for Payer: Cash Price |
$9.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.76
|
| Rate for Payer: Medical Associates Commercial |
$8.76
|
| Rate for Payer: Midlands Choice Commercial |
$8.18
|
| Rate for Payer: United Healthcare Commercial |
$10.51
|
|
|
carBAMazepine 200 mg Tab [VDMC]
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10373926
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Aetna of IA Commercial |
$3.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.15
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.63
|
| Rate for Payer: Medical Associates Commercial |
$2.63
|
| Rate for Payer: Midlands Choice Commercial |
$2.45
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
carBAMazepine 200 mg Tab [VDMC]
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10373926
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Aetna of IA Commercial |
$3.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.15
|
| Rate for Payer: Aetna of IA Medicare |
$2.00
|
| Rate for Payer: Amerigroup Medicaid |
$2.02
|
| Rate for Payer: Amerigroup Medicare |
$1.59
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.63
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.00
|
| Rate for Payer: Medical Associates Commercial |
$2.63
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.58
|
| Rate for Payer: Midlands Choice Commercial |
$2.45
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.81
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.07
|
|
