|
digoxin immune FAB 40 mg Inj SDV [VDMC]
|
Facility
|
IP
|
$8,236.48
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
10382928
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5,765.54 |
| Max. Negotiated Rate |
$7,412.83 |
| Rate for Payer: Aetna of IA Commercial |
$7,412.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,412.83
|
| Rate for Payer: Cash Price |
$6,589.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,177.36
|
| Rate for Payer: Medical Associates Commercial |
$6,177.36
|
| Rate for Payer: Midlands Choice Commercial |
$5,765.54
|
| Rate for Payer: United Healthcare Commercial |
$7,412.83
|
|
|
digoxin immune FAB 40 mg Inj SDV [VDMC]
|
Facility
|
OP
|
$8,236.48
|
|
|
Service Code
|
HCPCS J1162
|
| Hospital Charge Code |
10382928
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4,116.59 |
| Max. Negotiated Rate |
$7,412.83 |
| Rate for Payer: Aetna of IA Commercial |
$7,412.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,412.83
|
| Rate for Payer: Aetna of IA Medicare |
$4,694.79
|
| Rate for Payer: Amerigroup Medicaid |
$4,156.95
|
| Rate for Payer: Amerigroup Medicare |
$4,159.42
|
| Rate for Payer: Cash Price |
$6,589.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,177.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,118.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,116.59
|
| Rate for Payer: Medical Associates Commercial |
$6,177.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,118.24
|
| Rate for Payer: Midlands Choice Commercial |
$5,765.54
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,180.01
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$4,177.54
|
| Rate for Payer: Oscar Health of IA Commercial |
$6,177.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,177.36
|
| Rate for Payer: United Healthcare Commercial |
$7,412.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,859.52
|
|
|
DILANTIN (PHENYTOIN)
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
8093930
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Aetna of IA Medicare |
$63.27
|
| Rate for Payer: Amerigroup Medicaid |
$56.02
|
| Rate for Payer: Amerigroup Medicare |
$56.06
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.48
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.33
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$56.30
|
| Rate for Payer: Oscar Health of IA Commercial |
$83.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.25
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.49
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
DILANTIN (PHENYTOIN)
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
8093930
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
|
|
diltiazem 120 mg/24 hours ERCap [VDMC]
|
Facility
|
IP
|
$2.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383064
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna of IA Commercial |
$1.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.96
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.64
|
| Rate for Payer: Medical Associates Commercial |
$1.64
|
| Rate for Payer: Midlands Choice Commercial |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
|
|
diltiazem 120 mg/24 hours ERCap [VDMC]
|
Facility
|
OP
|
$2.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383064
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna of IA Commercial |
$1.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.96
|
| Rate for Payer: Aetna of IA Medicare |
$1.24
|
| Rate for Payer: Amerigroup Medicaid |
$1.10
|
| Rate for Payer: Amerigroup Medicare |
$1.10
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.09
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.09
|
| Rate for Payer: Medical Associates Commercial |
$1.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.09
|
| Rate for Payer: Midlands Choice Commercial |
$1.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.11
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.11
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.64
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.29
|
|
|
diltiazem 180 mg/24 hours ERCap [VDMC]
|
Facility
|
IP
|
$1.87
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Aetna of IA Commercial |
$1.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.68
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.40
|
| Rate for Payer: Medical Associates Commercial |
$1.40
|
| Rate for Payer: Midlands Choice Commercial |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.68
|
|
|
diltiazem 180 mg/24 hours ERCap [VDMC]
|
Facility
|
OP
|
$1.87
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383135
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Aetna of IA Commercial |
$1.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.68
|
| Rate for Payer: Aetna of IA Medicare |
$1.07
|
| Rate for Payer: Amerigroup Medicaid |
$0.94
|
| Rate for Payer: Amerigroup Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.40
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.93
|
| Rate for Payer: Medical Associates Commercial |
$1.40
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.94
|
| Rate for Payer: Midlands Choice Commercial |
$1.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.95
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.95
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.10
|
|
|
diltiazem 30 mg Tab [VDMC]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Aetna of IA Medicare |
$1.20
|
| Rate for Payer: Amerigroup Medicaid |
$1.06
|
| Rate for Payer: Amerigroup Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.05
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.06
|
| Rate for Payer: Midlands Choice Commercial |
$1.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.07
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.07
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.24
|
|
|
diltiazem 30 mg Tab [VDMC]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383351
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Midlands Choice Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
|
|
dilTIAZem 5 mg/mL 5ml vial SOL SDV [VDMC]
|
Facility
|
OP
|
$31.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15382673
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.55 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna of IA Commercial |
$28.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.00
|
| Rate for Payer: Aetna of IA Medicare |
$17.73
|
| Rate for Payer: Amerigroup Medicaid |
$15.70
|
| Rate for Payer: Amerigroup Medicare |
$15.71
|
| Rate for Payer: Cash Price |
$24.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.55
|
| Rate for Payer: Medical Associates Commercial |
$23.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.56
|
| Rate for Payer: Midlands Choice Commercial |
$21.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.79
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$15.78
|
| Rate for Payer: Oscar Health of IA Commercial |
$23.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.33
|
| Rate for Payer: United Healthcare Commercial |
$28.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.35
|
|
|
dilTIAZem 5 mg/mL 5ml vial SOL SDV [VDMC]
|
Facility
|
IP
|
$31.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15382673
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.78 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna of IA Commercial |
$28.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.00
|
| Rate for Payer: Cash Price |
$24.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.33
|
| Rate for Payer: Medical Associates Commercial |
$23.33
|
| Rate for Payer: Midlands Choice Commercial |
$21.78
|
| Rate for Payer: United Healthcare Commercial |
$28.00
|
|
|
diphenhydrAMINE 12.5 mg/5 mL 10 ml Oral Liq [VDMC]
|
Facility
|
IP
|
$7.59
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Aetna of IA Commercial |
$6.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.83
|
| Rate for Payer: Cash Price |
$6.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.69
|
| Rate for Payer: Medical Associates Commercial |
$5.69
|
| Rate for Payer: Midlands Choice Commercial |
$5.31
|
| Rate for Payer: United Healthcare Commercial |
$6.83
|
|
|
diphenhydrAMINE 12.5 mg/5 mL 10 ml Oral Liq [VDMC]
|
Facility
|
OP
|
$7.59
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383617
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Aetna of IA Commercial |
$6.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.83
|
| Rate for Payer: Aetna of IA Medicare |
$4.33
|
| Rate for Payer: Amerigroup Medicaid |
$3.83
|
| Rate for Payer: Amerigroup Medicare |
$3.83
|
| Rate for Payer: Cash Price |
$6.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.79
|
| Rate for Payer: Medical Associates Commercial |
$5.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.80
|
| Rate for Payer: Midlands Choice Commercial |
$5.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.85
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$3.85
|
| Rate for Payer: Oscar Health of IA Commercial |
$5.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.69
|
| Rate for Payer: United Healthcare Commercial |
$6.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.48
|
|
|
diphenhydrAMINE 25 mg Cap [VDMC]
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383688
|
|
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
|
|
|
diphenhydrAMINE 25 mg Cap [VDMC]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383688
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| 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 |
$0.64
|
| Rate for Payer: Amerigroup Medicaid |
$0.57
|
| Rate for Payer: Amerigroup Medicare |
$0.57
|
| 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 |
$0.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.56
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.57
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.57
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.57
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.67
|
|
|
diphenhydrAMINE 50 mg Cap [VDMC]
|
Facility
|
OP
|
$1.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383757
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of IA Commercial |
$1.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.05
|
| Rate for Payer: Aetna of IA Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicaid |
$0.59
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| 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 |
$0.58
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.59
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.59
|
| Rate for Payer: Oscar Health of IA Commercial |
$0.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.69
|
|
|
diphenhydrAMINE 50 mg Cap [VDMC]
|
Facility
|
IP
|
$1.17
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10383757
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of IA Commercial |
$1.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.05
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
|
|
diphenhydrAMINE 50 mg/mL 1ml SDV Inj [VDMC]
|
Facility
|
IP
|
$24.31
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
10429301
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.02 |
| Max. Negotiated Rate |
$21.88 |
| Rate for Payer: Aetna of IA Commercial |
$21.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.88
|
| Rate for Payer: Cash Price |
$19.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.23
|
| Rate for Payer: Medical Associates Commercial |
$18.23
|
| Rate for Payer: Midlands Choice Commercial |
$17.02
|
| Rate for Payer: United Healthcare Commercial |
$21.88
|
|
|
diphenhydrAMINE 50 mg/mL 1ml SDV Inj [VDMC]
|
Facility
|
OP
|
$24.31
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
10429301
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$21.88 |
| Rate for Payer: Aetna of IA Commercial |
$21.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.88
|
| Rate for Payer: Aetna of IA Medicare |
$13.86
|
| Rate for Payer: Amerigroup Medicaid |
$12.27
|
| Rate for Payer: Amerigroup Medicare |
$12.28
|
| Rate for Payer: Cash Price |
$19.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.23
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.15
|
| Rate for Payer: Medical Associates Commercial |
$18.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.16
|
| Rate for Payer: Midlands Choice Commercial |
$17.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.34
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.33
|
| Rate for Payer: Oscar Health of IA Commercial |
$18.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.23
|
| Rate for Payer: United Healthcare Commercial |
$21.88
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.34
|
|
|
diphtheria/hepB/pertussis,acel/polio/tetanus - Sus SDV [VDMC]
|
Facility
|
OP
|
$142.14
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
12453437
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.00 |
| Max. Negotiated Rate |
$127.93 |
| Rate for Payer: Aetna of IA Commercial |
$127.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.93
|
| Rate for Payer: Aetna of IA Medicare |
$81.02
|
| Rate for Payer: Amerigroup Medicaid |
$71.74
|
| Rate for Payer: Amerigroup Medicare |
$71.78
|
| Rate for Payer: Cash Price |
$113.71
|
| Rate for Payer: Cash Price |
$113.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$71.07
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$71.04
|
| Rate for Payer: Medical Associates Commercial |
$106.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$71.07
|
| Rate for Payer: Midlands Choice Commercial |
$99.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$72.14
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$72.09
|
| Rate for Payer: Oscar Health of IA Commercial |
$106.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$106.60
|
| Rate for Payer: United Healthcare Commercial |
$127.93
|
| Rate for Payer: United Healthcare Managed Medicare |
$83.86
|
| Rate for Payer: Wellmark IA HMO |
$62.00
|
| Rate for Payer: Wellmark IA PPO |
$68.20
|
|
|
diphtheria/hepB/pertussis,acel/polio/tetanus - Sus SDV [VDMC]
|
Facility
|
IP
|
$142.14
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
12453437
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$99.50 |
| Max. Negotiated Rate |
$127.93 |
| Rate for Payer: Aetna of IA Commercial |
$127.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.93
|
| Rate for Payer: Cash Price |
$113.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.60
|
| Rate for Payer: Medical Associates Commercial |
$106.60
|
| Rate for Payer: Midlands Choice Commercial |
$99.50
|
| Rate for Payer: United Healthcare Commercial |
$127.93
|
|
|
diphtheria/pertussis,acel/tetanus/polio - Sus SDV [VDMC]
|
Facility
|
IP
|
$107.15
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
12454583
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$96.44 |
| Rate for Payer: Aetna of IA Commercial |
$96.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$96.44
|
| Rate for Payer: Cash Price |
$85.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.36
|
| Rate for Payer: Medical Associates Commercial |
$80.36
|
| Rate for Payer: Midlands Choice Commercial |
$75.00
|
| Rate for Payer: United Healthcare Commercial |
$96.44
|
|
|
diphtheria/pertussis,acel/tetanus/polio - Sus SDV [VDMC]
|
Facility
|
OP
|
$107.15
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
12454583
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$96.44 |
| Rate for Payer: Aetna of IA Commercial |
$96.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$96.44
|
| Rate for Payer: Aetna of IA Medicare |
$61.08
|
| Rate for Payer: Amerigroup Medicaid |
$54.08
|
| Rate for Payer: Amerigroup Medicare |
$54.11
|
| Rate for Payer: Cash Price |
$85.72
|
| Rate for Payer: Cash Price |
$85.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$53.55
|
| Rate for Payer: Medical Associates Commercial |
$80.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.58
|
| Rate for Payer: Midlands Choice Commercial |
$75.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.38
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$54.35
|
| Rate for Payer: Oscar Health of IA Commercial |
$80.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$80.36
|
| Rate for Payer: United Healthcare Commercial |
$96.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.22
|
| Rate for Payer: Wellmark IA HMO |
$62.00
|
| Rate for Payer: Wellmark IA PPO |
$68.20
|
|
|
diphtheria/tetanus/pertussis (DTaP) ped 25 units-10 units-58 mcg/0.5 mL Sus UD [VDMC]
|
Facility
|
IP
|
$61.30
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
24148567
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.91 |
| Max. Negotiated Rate |
$55.17 |
| Rate for Payer: Aetna of IA Commercial |
$55.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.17
|
| Rate for Payer: Cash Price |
$49.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.98
|
| Rate for Payer: Medical Associates Commercial |
$45.98
|
| Rate for Payer: Midlands Choice Commercial |
$42.91
|
| Rate for Payer: United Healthcare Commercial |
$55.17
|
|
