|
DIABETES ED IND PROGRAM
|
Facility
|
OP
|
$1,255.00
|
|
|
Service Code
|
HCPCS S9455
|
| Hospital Charge Code |
8059032
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$564.75 |
| Max. Negotiated Rate |
$1,129.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,129.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,129.50
|
| Rate for Payer: Aetna of IA Medicare |
$715.35
|
| Rate for Payer: Amerigroup Medicaid |
$723.88
|
| Rate for Payer: Amerigroup Medicare |
$570.40
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$941.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$564.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$716.86
|
| Rate for Payer: Medical Associates Commercial |
$941.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$564.75
|
| Rate for Payer: Midlands Choice Commercial |
$878.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$727.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$649.46
|
| Rate for Payer: United Healthcare Commercial |
$1,129.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$740.45
|
|
|
DIABETES ED IND PROGRAM
|
Facility
|
IP
|
$1,255.00
|
|
|
Service Code
|
HCPCS S9455
|
| Hospital Charge Code |
8059032
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$878.50 |
| Max. Negotiated Rate |
$1,129.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,129.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,129.50
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$941.25
|
| Rate for Payer: Medical Associates Commercial |
$941.25
|
| Rate for Payer: Midlands Choice Commercial |
$878.50
|
| Rate for Payer: United Healthcare Commercial |
$1,129.50
|
|
|
DIABETES ED IND PROGRAM T19
|
Facility
|
IP
|
$1,255.00
|
|
|
Service Code
|
HCPCS S9455
|
| Hospital Charge Code |
7803727
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$878.50 |
| Max. Negotiated Rate |
$1,129.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,129.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,129.50
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$941.25
|
| Rate for Payer: Medical Associates Commercial |
$941.25
|
| Rate for Payer: Midlands Choice Commercial |
$878.50
|
| Rate for Payer: United Healthcare Commercial |
$1,129.50
|
|
|
DIABETES ED IND PROGRAM T19
|
Facility
|
OP
|
$1,255.00
|
|
|
Service Code
|
HCPCS S9455
|
| Hospital Charge Code |
7803727
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$564.75 |
| Max. Negotiated Rate |
$1,129.50 |
| Rate for Payer: Amerigroup Medicaid |
$723.88
|
| Rate for Payer: Amerigroup Medicare |
$570.40
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$941.25
|
| Rate for Payer: Aetna of IA Commercial |
$1,129.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,129.50
|
| Rate for Payer: Aetna of IA Medicare |
$715.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$564.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$716.86
|
| Rate for Payer: Medical Associates Commercial |
$941.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$564.75
|
| Rate for Payer: Midlands Choice Commercial |
$878.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$727.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$649.46
|
| Rate for Payer: United Healthcare Commercial |
$1,129.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$740.45
|
|
|
DIAGNOSTIC ANOSCOPY SPX
|
Professional
|
Both
|
$211.00
|
|
|
Service Code
|
CPT 46600
|
| Hospital Charge Code |
7982769
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$147.70 |
| Max. Negotiated Rate |
$158.25 |
| Rate for Payer: Cash Price |
$168.80
|
| Rate for Payer: Cash Price |
$168.80
|
| Rate for Payer: Medical Associates Commercial |
$158.25
|
| Rate for Payer: Midlands Choice Commercial |
$147.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$158.25
|
| Rate for Payer: United Healthcare Commercial |
$154.42
|
|
|
Diaper Cream Compound [VDMC]
|
Facility
|
IP
|
$8.87
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23278189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.21 |
| Max. Negotiated Rate |
$7.98 |
| Rate for Payer: Aetna of IA Commercial |
$7.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.98
|
| Rate for Payer: Cash Price |
$7.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.65
|
| Rate for Payer: Medical Associates Commercial |
$6.65
|
| Rate for Payer: Midlands Choice Commercial |
$6.21
|
| Rate for Payer: United Healthcare Commercial |
$7.98
|
|
|
Diaper Cream Compound [VDMC]
|
Facility
|
OP
|
$8.87
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23278189
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$7.98 |
| Rate for Payer: Aetna of IA Commercial |
$7.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.98
|
| Rate for Payer: Aetna of IA Medicare |
$5.05
|
| Rate for Payer: Amerigroup Medicaid |
$5.12
|
| Rate for Payer: Amerigroup Medicare |
$4.03
|
| Rate for Payer: Cash Price |
$7.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.65
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.99
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.07
|
| Rate for Payer: Medical Associates Commercial |
$6.65
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.99
|
| Rate for Payer: Midlands Choice Commercial |
$6.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.59
|
| Rate for Payer: United Healthcare Commercial |
$7.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.23
|
|
|
diazepam 2 mg Tab [VDMC]
|
Facility
|
OP
|
$3.21
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of IA Commercial |
$2.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.89
|
| Rate for Payer: Aetna of IA Medicare |
$1.83
|
| Rate for Payer: Amerigroup Medicaid |
$1.85
|
| Rate for Payer: Amerigroup Medicare |
$1.46
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.41
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.83
|
| Rate for Payer: Medical Associates Commercial |
$2.41
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.44
|
| Rate for Payer: Midlands Choice Commercial |
$2.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.66
|
| Rate for Payer: United Healthcare Commercial |
$2.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.89
|
|
|
diazepam 2 mg Tab [VDMC]
|
Facility
|
IP
|
$3.21
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of IA Commercial |
$2.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.89
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.41
|
| Rate for Payer: Medical Associates Commercial |
$2.41
|
| Rate for Payer: Midlands Choice Commercial |
$2.25
|
| Rate for Payer: United Healthcare Commercial |
$2.89
|
|
|
diazePAM 5 mg/mL 10 ml MDV vial [VDMC]
|
Facility
|
OP
|
$227.42
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
14377411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$102.34 |
| Max. Negotiated Rate |
$204.68 |
| Rate for Payer: Aetna of IA Commercial |
$204.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$204.68
|
| Rate for Payer: Aetna of IA Medicare |
$129.63
|
| Rate for Payer: Amerigroup Medicaid |
$131.18
|
| Rate for Payer: Amerigroup Medicare |
$103.36
|
| Rate for Payer: Cash Price |
$181.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$170.56
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$102.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$129.90
|
| Rate for Payer: Medical Associates Commercial |
$170.56
|
| Rate for Payer: Medical Associates Managed Medicare |
$102.34
|
| Rate for Payer: Midlands Choice Commercial |
$159.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$131.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$117.69
|
| Rate for Payer: United Healthcare Commercial |
$204.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$134.18
|
|
|
diazePAM 5 mg/mL 10 ml MDV vial [VDMC]
|
Facility
|
IP
|
$227.42
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
14377411
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$159.19 |
| Max. Negotiated Rate |
$204.68 |
| Rate for Payer: Aetna of IA Commercial |
$204.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$204.68
|
| Rate for Payer: Cash Price |
$181.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$170.56
|
| Rate for Payer: Medical Associates Commercial |
$170.56
|
| Rate for Payer: Midlands Choice Commercial |
$159.19
|
| Rate for Payer: United Healthcare Commercial |
$204.68
|
|
|
diazepam 5 mg/mL 2 ml SDV Inj syringe [VDMC]
|
Facility
|
OP
|
$92.25
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
10382374
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.51 |
| Max. Negotiated Rate |
$83.02 |
| Rate for Payer: Aetna of IA Commercial |
$83.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$83.02
|
| Rate for Payer: Aetna of IA Medicare |
$52.58
|
| Rate for Payer: Amerigroup Medicaid |
$53.21
|
| Rate for Payer: Amerigroup Medicare |
$41.93
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$69.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$41.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$52.69
|
| Rate for Payer: Medical Associates Commercial |
$69.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$41.51
|
| Rate for Payer: Midlands Choice Commercial |
$64.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$53.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.74
|
| Rate for Payer: United Healthcare Commercial |
$83.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$54.43
|
|
|
diazepam 5 mg/mL 2 ml SDV Inj syringe [VDMC]
|
Facility
|
IP
|
$92.25
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
10382374
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.57 |
| Max. Negotiated Rate |
$83.02 |
| Rate for Payer: Aetna of IA Commercial |
$83.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$83.02
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$69.19
|
| Rate for Payer: Medical Associates Commercial |
$69.19
|
| Rate for Payer: Midlands Choice Commercial |
$64.57
|
| Rate for Payer: United Healthcare Commercial |
$83.02
|
|
|
diazepam 5 mg Tab [VDMC]
|
Facility
|
OP
|
$3.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382305
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of IA Commercial |
$2.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.84
|
| Rate for Payer: Aetna of IA Medicare |
$1.80
|
| Rate for Payer: Amerigroup Medicaid |
$1.82
|
| Rate for Payer: Amerigroup Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.37
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.81
|
| Rate for Payer: Medical Associates Commercial |
$2.37
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.42
|
| Rate for Payer: Midlands Choice Commercial |
$2.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.64
|
| Rate for Payer: United Healthcare Commercial |
$2.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.86
|
|
|
diazepam 5 mg Tab [VDMC]
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382305
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of IA Commercial |
$2.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.84
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.37
|
| Rate for Payer: Medical Associates Commercial |
$2.37
|
| Rate for Payer: Midlands Choice Commercial |
$2.21
|
| Rate for Payer: United Healthcare Commercial |
$2.84
|
|
|
dibucaine topical 1% Oin[VDMC]
|
Facility
|
OP
|
$20.16
|
|
|
Service Code
|
NDC 00536-1211-95
|
| Hospital Charge Code |
13327364
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.07 |
| Max. Negotiated Rate |
$18.14 |
| Rate for Payer: Aetna of IA Commercial |
$18.14
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.14
|
| Rate for Payer: Aetna of IA Medicare |
$11.49
|
| Rate for Payer: Amerigroup Medicaid |
$11.63
|
| Rate for Payer: Amerigroup Medicare |
$9.16
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.07
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.52
|
| Rate for Payer: Medical Associates Commercial |
$15.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.07
|
| Rate for Payer: Midlands Choice Commercial |
$14.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.43
|
| Rate for Payer: United Healthcare Commercial |
$18.14
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.89
|
|
|
dibucaine topical 1% Oin[VDMC]
|
Facility
|
IP
|
$20.16
|
|
|
Service Code
|
NDC 00536-1211-95
|
| Hospital Charge Code |
13327364
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$18.14 |
| Rate for Payer: Aetna of IA Commercial |
$18.14
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.14
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.12
|
| Rate for Payer: Medical Associates Commercial |
$15.12
|
| Rate for Payer: Midlands Choice Commercial |
$14.11
|
| Rate for Payer: United Healthcare Commercial |
$18.14
|
|
|
diclofenac sodium 50 mg Oral EC Tab [VDMC]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| 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 |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.04
|
| 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 |
$0.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.75
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.68
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
diclofenac sodium 50 mg Oral EC Tab [VDMC]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382445
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| 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 |
$1.04
|
| 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 |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
|
|
diclofenac sodium 75 mg DR Oral EC Tab [VDMC]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382516
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of IA Commercial |
$1.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.28
|
| Rate for Payer: Aetna of IA Medicare |
$0.81
|
| Rate for Payer: Amerigroup Medicaid |
$0.82
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.81
|
| Rate for Payer: Medical Associates Commercial |
$1.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.64
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.84
|
|
|
diclofenac sodium 75 mg DR Oral EC Tab [VDMC]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382516
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of IA Commercial |
$1.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.28
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.07
|
| Rate for Payer: Medical Associates Commercial |
$1.07
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.28
|
|
|
diclofenac Top 1% gel [VDMC]
|
Facility
|
IP
|
$16.06
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.24 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna of IA Commercial |
$14.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.45
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.04
|
| Rate for Payer: Medical Associates Commercial |
$12.04
|
| Rate for Payer: Midlands Choice Commercial |
$11.24
|
| Rate for Payer: United Healthcare Commercial |
$14.45
|
|
|
diclofenac Top 1% gel [VDMC]
|
Facility
|
OP
|
$16.06
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10434323
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna of IA Commercial |
$14.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.45
|
| Rate for Payer: Aetna of IA Medicare |
$9.15
|
| Rate for Payer: Amerigroup Medicaid |
$9.26
|
| Rate for Payer: Amerigroup Medicare |
$7.30
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.04
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.23
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.17
|
| Rate for Payer: Medical Associates Commercial |
$12.04
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.23
|
| Rate for Payer: Midlands Choice Commercial |
$11.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.31
|
| Rate for Payer: United Healthcare Commercial |
$14.45
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.47
|
|
|
dicyclomine 20 mg Tab [VDMC]
|
Facility
|
OP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382646
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.83
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.82
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.65
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
|
dicyclomine 20 mg Tab [VDMC]
|
Facility
|
IP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382646
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
|
