|
cycloSPORINE microEmul 100 mg Cap [VDMC]
|
Facility
|
OP
|
$6.99
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380393
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$6.29 |
| Rate for Payer: Aetna of IA Commercial |
$6.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.29
|
| Rate for Payer: Aetna of IA Medicare |
$3.98
|
| Rate for Payer: Amerigroup Medicaid |
$3.53
|
| Rate for Payer: Amerigroup Medicare |
$3.53
|
| Rate for Payer: Cash Price |
$5.59
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.49
|
| Rate for Payer: Medical Associates Commercial |
$5.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.50
|
| Rate for Payer: Midlands Choice Commercial |
$4.89
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.55
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$3.55
|
| Rate for Payer: Oscar Health of IA Commercial |
$5.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.24
|
| Rate for Payer: United Healthcare Commercial |
$6.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.12
|
|
|
cycloSPORINE microEmul 100 mg Cap [VDMC]
|
Facility
|
IP
|
$6.99
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380393
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.89 |
| Max. Negotiated Rate |
$6.29 |
| Rate for Payer: Aetna of IA Commercial |
$6.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.29
|
| Rate for Payer: Cash Price |
$5.59
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.24
|
| Rate for Payer: Medical Associates Commercial |
$5.24
|
| Rate for Payer: Midlands Choice Commercial |
$4.89
|
| Rate for Payer: United Healthcare Commercial |
$6.29
|
|
|
cycloSPORINE microEmul 25 mg Cap [VDMC]
|
Facility
|
IP
|
$2.41
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380462
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna of IA Commercial |
$2.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.17
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.81
|
| Rate for Payer: Medical Associates Commercial |
$1.81
|
| Rate for Payer: Midlands Choice Commercial |
$1.69
|
| Rate for Payer: United Healthcare Commercial |
$2.17
|
|
|
cycloSPORINE microEmul 25 mg Cap [VDMC]
|
Facility
|
OP
|
$2.41
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380462
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna of IA Commercial |
$2.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.17
|
| Rate for Payer: Aetna of IA Medicare |
$1.37
|
| Rate for Payer: Amerigroup Medicaid |
$1.22
|
| Rate for Payer: Amerigroup Medicare |
$1.22
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.81
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.20
|
| Rate for Payer: Medical Associates Commercial |
$1.81
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.20
|
| Rate for Payer: Midlands Choice Commercial |
$1.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.22
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.22
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.81
|
| Rate for Payer: United Healthcare Commercial |
$2.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.42
|
|
|
cycloSPORINE Ophth 0.05% Emul [VDMC]
|
Facility
|
OP
|
$52.49
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$47.24 |
| Rate for Payer: Aetna of IA Commercial |
$47.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.24
|
| Rate for Payer: Aetna of IA Medicare |
$29.92
|
| Rate for Payer: Amerigroup Medicaid |
$26.49
|
| Rate for Payer: Amerigroup Medicare |
$26.51
|
| Rate for Payer: Cash Price |
$41.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.37
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.23
|
| Rate for Payer: Medical Associates Commercial |
$39.37
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.24
|
| Rate for Payer: Midlands Choice Commercial |
$36.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.64
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$26.62
|
| Rate for Payer: Oscar Health of IA Commercial |
$39.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.37
|
| Rate for Payer: United Healthcare Commercial |
$47.24
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.97
|
|
|
cycloSPORINE Ophth 0.05% Emul [VDMC]
|
Facility
|
IP
|
$52.49
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434258
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.74 |
| Max. Negotiated Rate |
$47.24 |
| Rate for Payer: Aetna of IA Commercial |
$47.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.24
|
| Rate for Payer: Cash Price |
$41.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.37
|
| Rate for Payer: Medical Associates Commercial |
$39.37
|
| Rate for Payer: Midlands Choice Commercial |
$36.74
|
| Rate for Payer: United Healthcare Commercial |
$47.24
|
|
|
cyproheptadine 4 mg Tab [VDMC]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of IA Commercial |
$1.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.18
|
| Rate for Payer: Aetna of IA Medicare |
$0.75
|
| Rate for Payer: Amerigroup Medicaid |
$0.66
|
| Rate for Payer: Amerigroup Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.66
|
| Rate for Payer: Midlands Choice Commercial |
$0.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.66
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
cyproheptadine 4 mg Tab [VDMC]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of IA Commercial |
$1.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.18
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Midlands Choice Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
|
|
Cystourethroscopy w/calibration/dilation of urethral stricture
|
Professional
|
Both
|
$907.00
|
|
|
Service Code
|
CPT 52281
|
| Hospital Charge Code |
8069090
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$137.29 |
| Max. Negotiated Rate |
$634.90 |
| Rate for Payer: Aetna of IA Medicare |
$137.29
|
| Rate for Payer: Amerigroup Medicaid |
$141.96
|
| Rate for Payer: Cash Price |
$725.60
|
| Rate for Payer: Cash Price |
$725.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$164.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$140.04
|
| Rate for Payer: Medical Associates Commercial |
$260.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$137.29
|
| Rate for Payer: Midlands Choice Commercial |
$634.90
|
| Rate for Payer: Oscar Health of IA Commercial |
$237.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$205.94
|
|
|
Cytomegalovirus DNA quant
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 87497
|
| Hospital Charge Code |
8505627
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$157.50 |
| Max. Negotiated Rate |
$202.50 |
| Rate for Payer: Aetna of IA Commercial |
$202.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$202.50
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$168.75
|
| Rate for Payer: Medical Associates Commercial |
$168.75
|
| Rate for Payer: Midlands Choice Commercial |
$157.50
|
| Rate for Payer: United Healthcare Commercial |
$202.50
|
|
|
Cytomegalovirus DNA quant
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 87497
|
| Hospital Charge Code |
8505627
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$68.82 |
| Max. Negotiated Rate |
$202.50 |
| Rate for Payer: Aetna of IA Commercial |
$202.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$202.50
|
| Rate for Payer: Aetna of IA Medicare |
$128.25
|
| Rate for Payer: Amerigroup Medicaid |
$113.56
|
| Rate for Payer: Amerigroup Medicare |
$113.62
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$168.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$112.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$112.46
|
| Rate for Payer: Medical Associates Commercial |
$168.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$112.50
|
| Rate for Payer: Midlands Choice Commercial |
$157.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$114.19
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$114.12
|
| Rate for Payer: Oscar Health of IA Commercial |
$168.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$168.75
|
| Rate for Payer: United Healthcare Commercial |
$202.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$132.75
|
| Rate for Payer: Wellmark IA HMO |
$68.82
|
| Rate for Payer: Wellmark IA PPO |
$75.70
|
|
|
Cytomegalovirus IgG Antibody DMCL
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 86644
|
| Hospital Charge Code |
8037833
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna of IA Commercial |
$106.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$106.20
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$88.50
|
| Rate for Payer: Medical Associates Commercial |
$88.50
|
| Rate for Payer: Midlands Choice Commercial |
$82.60
|
| Rate for Payer: United Healthcare Commercial |
$106.20
|
|
|
Cytomegalovirus IgG Antibody DMCL
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 86644
|
| Hospital Charge Code |
8037833
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna of IA Commercial |
$106.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$106.20
|
| Rate for Payer: Aetna of IA Medicare |
$67.26
|
| Rate for Payer: Amerigroup Medicaid |
$59.55
|
| Rate for Payer: Amerigroup Medicare |
$59.59
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$88.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$59.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$58.98
|
| Rate for Payer: Medical Associates Commercial |
$88.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.00
|
| Rate for Payer: Midlands Choice Commercial |
$82.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$59.88
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$59.85
|
| Rate for Payer: Oscar Health of IA Commercial |
$88.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$88.50
|
| Rate for Payer: United Healthcare Commercial |
$106.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$69.62
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
Cytomegalovirus IgM Antibody DMCL
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
8037834
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$96.60 |
| Max. Negotiated Rate |
$124.20 |
| Rate for Payer: Aetna of IA Commercial |
$124.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$124.20
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$103.50
|
| Rate for Payer: Medical Associates Commercial |
$103.50
|
| Rate for Payer: Midlands Choice Commercial |
$96.60
|
| Rate for Payer: United Healthcare Commercial |
$124.20
|
|
|
Cytomegalovirus IgM Antibody DMCL
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
CPT 86645
|
| Hospital Charge Code |
8037834
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$124.20 |
| Rate for Payer: Aetna of IA Commercial |
$124.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$124.20
|
| Rate for Payer: Aetna of IA Medicare |
$78.66
|
| Rate for Payer: Amerigroup Medicaid |
$69.65
|
| Rate for Payer: Amerigroup Medicare |
$69.69
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$103.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$69.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$68.97
|
| Rate for Payer: Medical Associates Commercial |
$103.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$69.00
|
| Rate for Payer: Midlands Choice Commercial |
$96.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.04
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$69.99
|
| Rate for Payer: Oscar Health of IA Commercial |
$103.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$103.50
|
| Rate for Payer: United Healthcare Commercial |
$124.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$81.42
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
dabigatran 75 mg Cap UD [VDMC]
|
Facility
|
IP
|
$31.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.99 |
| Max. Negotiated Rate |
$28.28 |
| Rate for Payer: Aetna of IA Commercial |
$28.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.28
|
| Rate for Payer: Cash Price |
$25.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.56
|
| Rate for Payer: Medical Associates Commercial |
$23.56
|
| Rate for Payer: Midlands Choice Commercial |
$21.99
|
| Rate for Payer: United Healthcare Commercial |
$28.28
|
|
|
dabigatran 75 mg Cap UD [VDMC]
|
Facility
|
OP
|
$31.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.70 |
| Max. Negotiated Rate |
$28.28 |
| Rate for Payer: Aetna of IA Commercial |
$28.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.28
|
| Rate for Payer: Aetna of IA Medicare |
$17.91
|
| Rate for Payer: Amerigroup Medicaid |
$15.86
|
| Rate for Payer: Amerigroup Medicare |
$15.87
|
| Rate for Payer: Cash Price |
$25.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.56
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.71
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.70
|
| Rate for Payer: Medical Associates Commercial |
$23.56
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.71
|
| Rate for Payer: Midlands Choice Commercial |
$21.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.95
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$15.94
|
| Rate for Payer: Oscar Health of IA Commercial |
$23.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.56
|
| Rate for Payer: United Healthcare Commercial |
$28.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.54
|
|
|
Dacarbazine 200 mg Pow SDV [VDMC]
|
Facility
|
IP
|
$107.72
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
19517248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$75.40 |
| Max. Negotiated Rate |
$96.95 |
| Rate for Payer: Aetna of IA Commercial |
$96.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$96.95
|
| Rate for Payer: Cash Price |
$86.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.79
|
| Rate for Payer: Medical Associates Commercial |
$80.79
|
| Rate for Payer: Midlands Choice Commercial |
$75.40
|
| Rate for Payer: United Healthcare Commercial |
$96.95
|
|
|
Dacarbazine 200 mg Pow SDV [VDMC]
|
Facility
|
OP
|
$107.72
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
19517248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.84 |
| Max. Negotiated Rate |
$96.95 |
| Rate for Payer: Aetna of IA Commercial |
$96.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$96.95
|
| Rate for Payer: Aetna of IA Medicare |
$61.40
|
| Rate for Payer: Amerigroup Medicaid |
$54.37
|
| Rate for Payer: Amerigroup Medicare |
$54.40
|
| Rate for Payer: Cash Price |
$86.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.79
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$53.84
|
| Rate for Payer: Medical Associates Commercial |
$80.79
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.86
|
| Rate for Payer: Midlands Choice Commercial |
$75.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.67
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$54.64
|
| Rate for Payer: Oscar Health of IA Commercial |
$80.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$80.79
|
| Rate for Payer: United Healthcare Commercial |
$96.95
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.55
|
|
|
dalbavancin 500 mg IV SDV Inj [VDMC]
|
Facility
|
OP
|
$6,371.96
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
27135791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3,184.71 |
| Max. Negotiated Rate |
$5,734.76 |
| Rate for Payer: Aetna of IA Commercial |
$5,734.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,734.76
|
| Rate for Payer: Aetna of IA Medicare |
$3,632.02
|
| Rate for Payer: Amerigroup Medicaid |
$3,215.93
|
| Rate for Payer: Amerigroup Medicare |
$3,217.84
|
| Rate for Payer: Cash Price |
$5,097.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,778.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,185.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,184.71
|
| Rate for Payer: Medical Associates Commercial |
$4,778.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,185.98
|
| Rate for Payer: Midlands Choice Commercial |
$4,460.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,233.77
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$3,231.86
|
| Rate for Payer: Oscar Health of IA Commercial |
$4,778.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,778.97
|
| Rate for Payer: United Healthcare Commercial |
$5,734.76
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,759.46
|
|
|
dalbavancin 500 mg IV SDV Inj [VDMC]
|
Facility
|
IP
|
$6,371.96
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
27135791
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,460.37 |
| Max. Negotiated Rate |
$5,734.76 |
| Rate for Payer: Aetna of IA Commercial |
$5,734.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,734.76
|
| Rate for Payer: Cash Price |
$5,097.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,778.97
|
| Rate for Payer: Medical Associates Commercial |
$4,778.97
|
| Rate for Payer: Midlands Choice Commercial |
$4,460.37
|
| Rate for Payer: United Healthcare Commercial |
$5,734.76
|
|
|
dantrolene 250 mg Pow SDV [VDMC]
|
Facility
|
OP
|
$4,048.04
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
23152470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,023.21 |
| Max. Negotiated Rate |
$3,643.24 |
| Rate for Payer: Aetna of IA Commercial |
$3,643.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,643.24
|
| Rate for Payer: Aetna of IA Medicare |
$2,307.38
|
| Rate for Payer: Amerigroup Medicaid |
$2,043.05
|
| Rate for Payer: Amerigroup Medicare |
$2,044.26
|
| Rate for Payer: Cash Price |
$3,238.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,036.03
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,024.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,023.21
|
| Rate for Payer: Medical Associates Commercial |
$3,036.03
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,024.02
|
| Rate for Payer: Midlands Choice Commercial |
$2,833.63
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,054.38
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$2,053.17
|
| Rate for Payer: Oscar Health of IA Commercial |
$3,036.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,036.03
|
| Rate for Payer: United Healthcare Commercial |
$3,643.24
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,388.34
|
|
|
dantrolene 250 mg Pow SDV [VDMC]
|
Facility
|
IP
|
$4,048.04
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
23152470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2,833.63 |
| Max. Negotiated Rate |
$3,643.24 |
| Rate for Payer: Aetna of IA Commercial |
$3,643.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,643.24
|
| Rate for Payer: Cash Price |
$3,238.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,036.03
|
| Rate for Payer: Medical Associates Commercial |
$3,036.03
|
| Rate for Payer: Midlands Choice Commercial |
$2,833.63
|
| Rate for Payer: United Healthcare Commercial |
$3,643.24
|
|
|
dantrolene 25 mg Cap [VDMC]
|
Facility
|
IP
|
$6.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna of IA Commercial |
$5.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.50
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.58
|
| Rate for Payer: Medical Associates Commercial |
$4.58
|
| Rate for Payer: Midlands Choice Commercial |
$4.28
|
| Rate for Payer: United Healthcare Commercial |
$5.50
|
|
|
dantrolene 25 mg Cap [VDMC]
|
Facility
|
OP
|
$6.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna of IA Commercial |
$5.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.50
|
| Rate for Payer: Aetna of IA Medicare |
$3.48
|
| Rate for Payer: Amerigroup Medicaid |
$3.08
|
| Rate for Payer: Amerigroup Medicare |
$3.09
|
| Rate for Payer: Cash Price |
$4.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.58
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.05
|
| Rate for Payer: Medical Associates Commercial |
$4.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.06
|
| Rate for Payer: Midlands Choice Commercial |
$4.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.10
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$3.10
|
| Rate for Payer: Oscar Health of IA Commercial |
$4.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.58
|
| Rate for Payer: United Healthcare Commercial |
$5.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.60
|
|
