|
ceFAZolin 1 g SDV Inj [VDMC]
|
Facility
|
OP
|
$25.90
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
10374973
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$23.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.31
|
| Rate for Payer: Aetna of IA Medicare |
$14.76
|
| Rate for Payer: Amerigroup Medicaid |
$14.94
|
| Rate for Payer: Amerigroup Medicare |
$11.77
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.79
|
| Rate for Payer: Medical Associates Commercial |
$19.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.65
|
| Rate for Payer: Midlands Choice Commercial |
$18.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.40
|
| Rate for Payer: United Healthcare Commercial |
$23.31
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.28
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ceFAZolin 1 g SDV Inj [VDMC]
|
Facility
|
IP
|
$25.90
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
10374973
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna of IA Commercial |
$23.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.31
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.42
|
| Rate for Payer: Medical Associates Commercial |
$19.42
|
| Rate for Payer: Midlands Choice Commercial |
$18.13
|
| Rate for Payer: United Healthcare Commercial |
$23.31
|
|
|
ceFAZolin 2 g/50 mL Premix [VDMC]
|
Facility
|
OP
|
$100.38
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
10375111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.17 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$90.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$90.34
|
| Rate for Payer: Aetna of IA Medicare |
$57.22
|
| Rate for Payer: Amerigroup Medicaid |
$57.90
|
| Rate for Payer: Amerigroup Medicare |
$45.62
|
| Rate for Payer: Cash Price |
$80.31
|
| Rate for Payer: Cash Price |
$80.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$75.29
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$45.17
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$57.34
|
| Rate for Payer: Medical Associates Commercial |
$75.29
|
| Rate for Payer: Medical Associates Managed Medicare |
$45.17
|
| Rate for Payer: Midlands Choice Commercial |
$70.27
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$58.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$51.95
|
| Rate for Payer: United Healthcare Commercial |
$90.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$59.23
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
ceFAZolin 2 g/50 mL Premix [VDMC]
|
Facility
|
IP
|
$100.38
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
10375111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$70.27 |
| Max. Negotiated Rate |
$90.34 |
| Rate for Payer: Aetna of IA Commercial |
$90.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$90.34
|
| Rate for Payer: Cash Price |
$80.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$75.29
|
| Rate for Payer: Medical Associates Commercial |
$75.29
|
| Rate for Payer: Midlands Choice Commercial |
$70.27
|
| Rate for Payer: United Healthcare Commercial |
$90.34
|
|
|
ceFAZolin 500 mg SDV Inj [VDMC]
|
Facility
|
IP
|
$23.28
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
10375180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$20.95 |
| Rate for Payer: Aetna of IA Commercial |
$20.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.95
|
| Rate for Payer: Cash Price |
$18.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.46
|
| Rate for Payer: Medical Associates Commercial |
$17.46
|
| Rate for Payer: Midlands Choice Commercial |
$16.29
|
| Rate for Payer: United Healthcare Commercial |
$20.95
|
|
|
ceFAZolin 500 mg SDV Inj [VDMC]
|
Facility
|
OP
|
$23.28
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
10375180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.47 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.95
|
| Rate for Payer: Aetna of IA Medicare |
$13.27
|
| Rate for Payer: Amerigroup Medicaid |
$13.43
|
| Rate for Payer: Amerigroup Medicare |
$10.58
|
| Rate for Payer: Cash Price |
$18.62
|
| Rate for Payer: Cash Price |
$18.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.46
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.29
|
| Rate for Payer: Medical Associates Commercial |
$17.46
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.47
|
| Rate for Payer: Midlands Choice Commercial |
$16.29
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.04
|
| Rate for Payer: United Healthcare Commercial |
$20.95
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.73
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
cefdinir 250 mg/5 mL Pow 60ml Suspension[VDMC]
|
Facility
|
OP
|
$56.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14015952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.29 |
| Max. Negotiated Rate |
$50.58 |
| Rate for Payer: Aetna of IA Commercial |
$50.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.58
|
| Rate for Payer: Aetna of IA Medicare |
$32.03
|
| Rate for Payer: Amerigroup Medicaid |
$32.42
|
| Rate for Payer: Amerigroup Medicare |
$25.54
|
| Rate for Payer: Cash Price |
$44.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$25.29
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.10
|
| Rate for Payer: Medical Associates Commercial |
$42.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.29
|
| Rate for Payer: Midlands Choice Commercial |
$39.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$29.08
|
| Rate for Payer: United Healthcare Commercial |
$50.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.16
|
|
|
cefdinir 250 mg/5 mL Pow 60ml Suspension[VDMC]
|
Facility
|
IP
|
$56.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14015952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.34 |
| Max. Negotiated Rate |
$50.58 |
| Rate for Payer: Aetna of IA Commercial |
$50.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.58
|
| Rate for Payer: Cash Price |
$44.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.15
|
| Rate for Payer: Medical Associates Commercial |
$42.15
|
| Rate for Payer: Midlands Choice Commercial |
$39.34
|
| Rate for Payer: United Healthcare Commercial |
$50.58
|
|
|
cefdinir 300 mg Cap [VDMC]
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10375318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Aetna of IA Commercial |
$2.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.55
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.13
|
| Rate for Payer: Medical Associates Commercial |
$2.13
|
| Rate for Payer: Midlands Choice Commercial |
$1.99
|
| Rate for Payer: United Healthcare Commercial |
$2.55
|
|
|
cefdinir 300 mg Cap [VDMC]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10375318
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Aetna of IA Commercial |
$2.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.55
|
| Rate for Payer: Aetna of IA Medicare |
$1.62
|
| Rate for Payer: Amerigroup Medicaid |
$1.64
|
| Rate for Payer: Amerigroup Medicare |
$1.29
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.13
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.62
|
| Rate for Payer: Medical Associates Commercial |
$2.13
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.28
|
| Rate for Payer: Midlands Choice Commercial |
$1.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.47
|
| Rate for Payer: United Healthcare Commercial |
$2.55
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.67
|
|
|
cefepime 1 g Pow SDV [VDMC]
|
Facility
|
IP
|
$29.44
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
10375387
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.61 |
| Max. Negotiated Rate |
$26.49 |
| Rate for Payer: Aetna of IA Commercial |
$26.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.49
|
| Rate for Payer: Cash Price |
$23.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.08
|
| Rate for Payer: Medical Associates Commercial |
$22.08
|
| Rate for Payer: Midlands Choice Commercial |
$20.61
|
| Rate for Payer: United Healthcare Commercial |
$26.49
|
|
|
cefepime 1 g Pow SDV [VDMC]
|
Facility
|
OP
|
$29.44
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
10375387
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$26.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.49
|
| Rate for Payer: Aetna of IA Medicare |
$16.78
|
| Rate for Payer: Amerigroup Medicaid |
$16.98
|
| Rate for Payer: Amerigroup Medicare |
$13.38
|
| Rate for Payer: Cash Price |
$23.55
|
| Rate for Payer: Cash Price |
$23.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.81
|
| Rate for Payer: Medical Associates Commercial |
$22.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.25
|
| Rate for Payer: Midlands Choice Commercial |
$20.61
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.23
|
| Rate for Payer: United Healthcare Commercial |
$26.49
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.37
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
cefepime 2 g SDV [VDMC]
|
Facility
|
IP
|
$37.59
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
16563344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.31 |
| Max. Negotiated Rate |
$33.83 |
| Rate for Payer: Aetna of IA Commercial |
$33.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$33.83
|
| Rate for Payer: Cash Price |
$30.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.19
|
| Rate for Payer: Medical Associates Commercial |
$28.19
|
| Rate for Payer: Midlands Choice Commercial |
$26.31
|
| Rate for Payer: United Healthcare Commercial |
$33.83
|
|
|
cefepime 2 g SDV [VDMC]
|
Facility
|
OP
|
$37.59
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
16563344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$33.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$33.83
|
| Rate for Payer: Aetna of IA Medicare |
$21.43
|
| Rate for Payer: Amerigroup Medicaid |
$21.68
|
| Rate for Payer: Amerigroup Medicare |
$17.08
|
| Rate for Payer: Cash Price |
$30.07
|
| Rate for Payer: Cash Price |
$30.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$16.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.47
|
| Rate for Payer: Medical Associates Commercial |
$28.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.91
|
| Rate for Payer: Midlands Choice Commercial |
$26.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.45
|
| Rate for Payer: United Healthcare Commercial |
$33.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.18
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
cefOXitin 2 g Inj SDV [VDMC]
|
Facility
|
OP
|
$39.50
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
10375724
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.78 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$35.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$35.55
|
| Rate for Payer: Aetna of IA Medicare |
$22.52
|
| Rate for Payer: Amerigroup Medicaid |
$22.78
|
| Rate for Payer: Amerigroup Medicare |
$17.95
|
| Rate for Payer: Cash Price |
$31.60
|
| Rate for Payer: Cash Price |
$31.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$29.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.56
|
| Rate for Payer: Medical Associates Commercial |
$29.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.78
|
| Rate for Payer: Midlands Choice Commercial |
$27.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.44
|
| Rate for Payer: United Healthcare Commercial |
$35.55
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.30
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
cefOXitin 2 g Inj SDV [VDMC]
|
Facility
|
IP
|
$39.50
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
10375724
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.65 |
| Max. Negotiated Rate |
$35.55 |
| Rate for Payer: Aetna of IA Commercial |
$35.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$35.55
|
| Rate for Payer: Cash Price |
$31.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$29.62
|
| Rate for Payer: Medical Associates Commercial |
$29.62
|
| Rate for Payer: Midlands Choice Commercial |
$27.65
|
| Rate for Payer: United Healthcare Commercial |
$35.55
|
|
|
cefprozil 250 mg/5 mL Pow 50ml susp [VDMC]
|
Facility
|
OP
|
$114.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14024667
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$51.70 |
| Max. Negotiated Rate |
$103.39 |
| Rate for Payer: Aetna of IA Commercial |
$103.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.39
|
| Rate for Payer: Aetna of IA Medicare |
$65.48
|
| Rate for Payer: Amerigroup Medicaid |
$66.26
|
| Rate for Payer: Amerigroup Medicare |
$52.21
|
| Rate for Payer: Cash Price |
$91.90
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.62
|
| Rate for Payer: Medical Associates Commercial |
$86.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.70
|
| Rate for Payer: Midlands Choice Commercial |
$80.42
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$59.45
|
| Rate for Payer: United Healthcare Commercial |
$103.39
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.78
|
|
|
cefprozil 250 mg/5 mL Pow 50ml susp [VDMC]
|
Facility
|
IP
|
$114.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14024667
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.42 |
| Max. Negotiated Rate |
$103.39 |
| Rate for Payer: Aetna of IA Commercial |
$103.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.39
|
| Rate for Payer: Cash Price |
$91.90
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.16
|
| Rate for Payer: Medical Associates Commercial |
$86.16
|
| Rate for Payer: Midlands Choice Commercial |
$80.42
|
| Rate for Payer: United Healthcare Commercial |
$103.39
|
|
|
cefTAZidime 1 g Inj SDV [VDMC]
|
Facility
|
IP
|
$30.60
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
10375931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$27.54 |
| Rate for Payer: Aetna of IA Commercial |
$27.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.54
|
| Rate for Payer: Cash Price |
$24.48
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.95
|
| Rate for Payer: Medical Associates Commercial |
$22.95
|
| Rate for Payer: Midlands Choice Commercial |
$21.42
|
| Rate for Payer: United Healthcare Commercial |
$27.54
|
|
|
cefTAZidime 1 g Inj SDV [VDMC]
|
Facility
|
OP
|
$30.60
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
10375931
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$27.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.54
|
| Rate for Payer: Aetna of IA Medicare |
$17.44
|
| Rate for Payer: Amerigroup Medicaid |
$17.65
|
| Rate for Payer: Amerigroup Medicare |
$13.91
|
| Rate for Payer: Cash Price |
$24.48
|
| Rate for Payer: Cash Price |
$24.48
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.48
|
| Rate for Payer: Medical Associates Commercial |
$22.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.77
|
| Rate for Payer: Midlands Choice Commercial |
$21.42
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.83
|
| Rate for Payer: United Healthcare Commercial |
$27.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.05
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
cefTAZidime 2 g Inj SDV [VDMC]
|
Facility
|
IP
|
$42.22
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
10376000
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.55 |
| Max. Negotiated Rate |
$37.99 |
| Rate for Payer: Aetna of IA Commercial |
$37.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.99
|
| Rate for Payer: Cash Price |
$33.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.66
|
| Rate for Payer: Medical Associates Commercial |
$31.66
|
| Rate for Payer: Midlands Choice Commercial |
$29.55
|
| Rate for Payer: United Healthcare Commercial |
$37.99
|
|
|
cefTAZidime 2 g Inj SDV [VDMC]
|
Facility
|
OP
|
$42.22
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
10376000
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$37.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.99
|
| Rate for Payer: Aetna of IA Medicare |
$24.06
|
| Rate for Payer: Amerigroup Medicaid |
$24.35
|
| Rate for Payer: Amerigroup Medicare |
$19.19
|
| Rate for Payer: Cash Price |
$33.77
|
| Rate for Payer: Cash Price |
$33.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.11
|
| Rate for Payer: Medical Associates Commercial |
$31.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.00
|
| Rate for Payer: Midlands Choice Commercial |
$29.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.85
|
| Rate for Payer: United Healthcare Commercial |
$37.99
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.91
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
cefTRIAXone 1 g Inj SDV [VDMC]
|
Facility
|
OP
|
$22.84
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
10376138
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.28 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.56
|
| Rate for Payer: Aetna of IA Medicare |
$13.02
|
| Rate for Payer: Amerigroup Medicaid |
$13.18
|
| Rate for Payer: Amerigroup Medicare |
$10.38
|
| Rate for Payer: Cash Price |
$18.28
|
| Rate for Payer: Cash Price |
$18.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.13
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.05
|
| Rate for Payer: Medical Associates Commercial |
$17.13
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.28
|
| Rate for Payer: Midlands Choice Commercial |
$15.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.82
|
| Rate for Payer: United Healthcare Commercial |
$20.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.48
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
cefTRIAXone 1 g Inj SDV [VDMC]
|
Facility
|
IP
|
$22.84
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
10376138
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.99 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna of IA Commercial |
$20.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.56
|
| Rate for Payer: Cash Price |
$18.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.13
|
| Rate for Payer: Medical Associates Commercial |
$17.13
|
| Rate for Payer: Midlands Choice Commercial |
$15.99
|
| Rate for Payer: United Healthcare Commercial |
$20.56
|
|
|
cefTRIAXone 250 mg Inj SDV [VDMC]
|
Facility
|
OP
|
$22.77
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
10376276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.49
|
| Rate for Payer: Aetna of IA Medicare |
$12.98
|
| Rate for Payer: Amerigroup Medicaid |
$13.13
|
| Rate for Payer: Amerigroup Medicare |
$10.35
|
| Rate for Payer: Cash Price |
$18.22
|
| Rate for Payer: Cash Price |
$18.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.01
|
| Rate for Payer: Medical Associates Commercial |
$17.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.25
|
| Rate for Payer: Midlands Choice Commercial |
$15.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.78
|
| Rate for Payer: United Healthcare Commercial |
$20.49
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.44
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
