|
cyclopentolate ophthalmic 1% 15ml SDV [VDMC]
|
Facility
|
IP
|
$53.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
21434014
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$37.21 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna of IA Commercial |
$47.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.84
|
| Rate for Payer: Cash Price |
$42.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.87
|
| Rate for Payer: Medical Associates Commercial |
$39.87
|
| Rate for Payer: Midlands Choice Commercial |
$37.21
|
| Rate for Payer: United Healthcare Commercial |
$47.84
|
|
|
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 |
$3.15 |
| 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 |
$3.99
|
| Rate for Payer: Amerigroup Medicaid |
$4.03
|
| Rate for Payer: Amerigroup Medicare |
$3.18
|
| 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 |
$3.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.99
|
| Rate for Payer: Medical Associates Commercial |
$5.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.15
|
| Rate for Payer: Midlands Choice Commercial |
$4.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.62
|
| Rate for Payer: United Healthcare Commercial |
$6.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.13
|
|
|
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 |
$4.90 |
| 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 |
$4.90
|
| 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 |
$1.68 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of IA Commercial |
$2.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.16
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.80
|
| Rate for Payer: Medical Associates Commercial |
$1.80
|
| Rate for Payer: Midlands Choice Commercial |
$1.68
|
| Rate for Payer: United Healthcare Commercial |
$2.16
|
|
|
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 |
$1.08 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of IA Commercial |
$2.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.16
|
| Rate for Payer: Aetna of IA Medicare |
$1.37
|
| Rate for Payer: Amerigroup Medicaid |
$1.39
|
| Rate for Payer: Amerigroup Medicare |
$1.09
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.37
|
| Rate for Payer: Medical Associates Commercial |
$1.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$2.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.42
|
|
|
cyproheptadine 4 mg Tab [VDMC]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| 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 |
$0.75
|
| Rate for Payer: Amerigroup Medicaid |
$0.76
|
| Rate for Payer: Amerigroup Medicare |
$0.60
|
| 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 |
$0.59
|
| 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 |
$0.92
|
| 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
|
|
|
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
|
|
|
CYSTOSCOPY
|
Facility
|
OP
|
$1,414.00
|
|
|
Service Code
|
CPT 52000
|
| Hospital Charge Code |
7983011
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$636.30 |
| Max. Negotiated Rate |
$2,940.47 |
| Rate for Payer: Aetna of IA Commercial |
$1,272.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,272.60
|
| Rate for Payer: Aetna of IA Medicare |
$805.98
|
| Rate for Payer: Amerigroup Medicaid |
$815.60
|
| Rate for Payer: Amerigroup Medicare |
$642.66
|
| Rate for Payer: Cash Price |
$1,131.20
|
| Rate for Payer: Cash Price |
$1,131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,060.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$636.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$807.68
|
| Rate for Payer: Medical Associates Commercial |
$1,060.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$636.30
|
| Rate for Payer: Midlands Choice Commercial |
$989.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$819.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$731.74
|
| Rate for Payer: United Healthcare Commercial |
$1,272.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$834.26
|
| Rate for Payer: Wellmark IA HMO WHPI |
$2,669.39
|
| Rate for Payer: Wellmark IA PPO |
$2,940.47
|
|
|
CYSTOSCOPY
|
Facility
|
IP
|
$1,414.00
|
|
|
Service Code
|
CPT 52000
|
| Hospital Charge Code |
7983011
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$989.80 |
| Max. Negotiated Rate |
$1,272.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,272.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,272.60
|
| Rate for Payer: Cash Price |
$1,131.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,060.50
|
| Rate for Payer: Medical Associates Commercial |
$1,060.50
|
| Rate for Payer: Midlands Choice Commercial |
$989.80
|
| Rate for Payer: United Healthcare Commercial |
$1,272.60
|
|
|
CYSTOSCOPY AND TREATMENT
|
Facility
|
OP
|
$2,713.00
|
|
|
Service Code
|
CPT 52281
|
| Hospital Charge Code |
7983010
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,220.85 |
| Max. Negotiated Rate |
$2,940.47 |
| Rate for Payer: Aetna of IA Commercial |
$2,441.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,441.70
|
| Rate for Payer: Aetna of IA Medicare |
$1,546.41
|
| Rate for Payer: Amerigroup Medicaid |
$1,564.86
|
| Rate for Payer: Amerigroup Medicare |
$1,233.06
|
| Rate for Payer: Cash Price |
$2,170.40
|
| Rate for Payer: Cash Price |
$2,170.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,034.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,220.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,549.67
|
| Rate for Payer: Medical Associates Commercial |
$2,034.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,220.85
|
| Rate for Payer: Midlands Choice Commercial |
$1,899.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,572.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,403.98
|
| Rate for Payer: United Healthcare Commercial |
$2,441.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,600.67
|
| Rate for Payer: Wellmark IA HMO WHPI |
$2,669.39
|
| Rate for Payer: Wellmark IA PPO |
$2,940.47
|
|
|
CYSTOSCOPY AND TREATMENT
|
Facility
|
IP
|
$2,713.00
|
|
|
Service Code
|
CPT 52281
|
| Hospital Charge Code |
7983010
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,899.10 |
| Max. Negotiated Rate |
$2,441.70 |
| Rate for Payer: Aetna of IA Commercial |
$2,441.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,441.70
|
| Rate for Payer: Cash Price |
$2,170.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,034.75
|
| Rate for Payer: Medical Associates Commercial |
$2,034.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,899.10
|
| Rate for Payer: United Healthcare Commercial |
$2,441.70
|
|
|
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 |
$248.30 |
| Max. Negotiated Rate |
$721.50 |
| Rate for Payer: Amerigroup Medicaid |
$250.73
|
| Rate for Payer: Cash Price |
$725.60
|
| Rate for Payer: Cash Price |
$725.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$248.30
|
| Rate for Payer: Medical Associates Commercial |
$680.25
|
| Rate for Payer: Midlands Choice Commercial |
$634.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$249.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$680.25
|
| Rate for Payer: United Healthcare Commercial |
$485.58
|
| Rate for Payer: Wellmark IA HMO WHPI |
$613.30
|
| Rate for Payer: Wellmark IA PPO |
$721.50
|
|
|
Cytomegalovirus DNA quant
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 87497
|
| Hospital Charge Code |
8505627
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$86.50 |
| 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: Aetna of IA Medicare |
$128.25
|
| Rate for Payer: Amerigroup Medicaid |
$129.78
|
| Rate for Payer: Amerigroup Medicare |
$102.26
|
| 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 |
$101.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$128.52
|
| Rate for Payer: Medical Associates Commercial |
$168.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$101.25
|
| Rate for Payer: Midlands Choice Commercial |
$157.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$130.41
|
| Rate for Payer: Partners Health Alliance Commercial |
$116.44
|
| Rate for Payer: United Healthcare Commercial |
$202.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$132.75
|
| Rate for Payer: Wellmark IA HMO WHPI |
$86.50
|
| Rate for Payer: Wellmark IA PPO |
$95.28
|
|
|
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 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 |
$41.83 |
| 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 |
$68.06
|
| Rate for Payer: Amerigroup Medicare |
$53.63
|
| 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 |
$53.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.40
|
| Rate for Payer: Medical Associates Commercial |
$88.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.10
|
| Rate for Payer: Midlands Choice Commercial |
$82.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.06
|
| Rate for Payer: United Healthcare Commercial |
$106.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$69.62
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
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 |
$41.83 |
| 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 |
$79.60
|
| Rate for Payer: Amerigroup Medicare |
$62.72
|
| 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 |
$62.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$78.83
|
| Rate for Payer: Medical Associates Commercial |
$103.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$62.10
|
| Rate for Payer: Midlands Choice Commercial |
$96.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$79.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$71.42
|
| Rate for Payer: United Healthcare Commercial |
$124.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$81.42
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
dabigatran 75 mg Cap UD [VDMC]
|
Facility
|
OP
|
$12.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Aetna of IA Commercial |
$11.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.30
|
| Rate for Payer: Aetna of IA Medicare |
$7.16
|
| Rate for Payer: Amerigroup Medicaid |
$7.24
|
| Rate for Payer: Amerigroup Medicare |
$5.71
|
| Rate for Payer: Cash Price |
$10.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.17
|
| Rate for Payer: Medical Associates Commercial |
$9.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.65
|
| Rate for Payer: Midlands Choice Commercial |
$8.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.50
|
| Rate for Payer: United Healthcare Commercial |
$11.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.41
|
|
|
dabigatran 75 mg Cap UD [VDMC]
|
Facility
|
IP
|
$12.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.79 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Aetna of IA Commercial |
$11.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.30
|
| Rate for Payer: Cash Price |
$10.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.42
|
| Rate for Payer: Medical Associates Commercial |
$9.42
|
| Rate for Payer: Midlands Choice Commercial |
$8.79
|
| Rate for Payer: United Healthcare Commercial |
$11.30
|
|
|
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 |
$1,821.62 |
| 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 |
$2,334.91
|
| Rate for Payer: Amerigroup Medicare |
$1,839.83
|
| 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 |
$1,821.62
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,312.24
|
| Rate for Payer: Medical Associates Commercial |
$3,036.03
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,821.62
|
| Rate for Payer: Midlands Choice Commercial |
$2,833.63
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,346.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,094.86
|
| 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 |
$4.27 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Aetna of IA Commercial |
$5.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.49
|
| 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 |
$4.27
|
| Rate for Payer: United Healthcare Commercial |
$5.49
|
|
|
dantrolene 25 mg Cap [VDMC]
|
Facility
|
OP
|
$6.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Aetna of IA Commercial |
$5.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.49
|
| Rate for Payer: Aetna of IA Medicare |
$3.48
|
| Rate for Payer: Amerigroup Medicaid |
$3.52
|
| Rate for Payer: Amerigroup Medicare |
$2.77
|
| 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 |
$2.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.49
|
| Rate for Payer: Medical Associates Commercial |
$4.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.75
|
| Rate for Payer: Midlands Choice Commercial |
$4.27
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.16
|
| Rate for Payer: United Healthcare Commercial |
$5.49
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.60
|
|
|
dapsone 25 mg Tab [VDMC]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10380882
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Aetna of IA Commercial |
$7.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.28
|
| Rate for Payer: Aetna of IA Medicare |
$4.61
|
| Rate for Payer: Amerigroup Medicaid |
$4.67
|
| Rate for Payer: Amerigroup Medicare |
$3.68
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.62
|
| Rate for Payer: Medical Associates Commercial |
$6.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.64
|
| Rate for Payer: Midlands Choice Commercial |
$5.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.19
|
| Rate for Payer: United Healthcare Commercial |
$7.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.77
|
|
