|
enoxaparin 100 mg/mL 1ml SDV syringe [VDMC]
|
Facility
|
IP
|
$44.50
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10385695
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.15 |
| Max. Negotiated Rate |
$40.05 |
| Rate for Payer: Aetna of IA Commercial |
$40.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$40.05
|
| Rate for Payer: Cash Price |
$35.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.38
|
| Rate for Payer: Medical Associates Commercial |
$33.38
|
| Rate for Payer: Midlands Choice Commercial |
$31.15
|
| Rate for Payer: United Healthcare Commercial |
$40.05
|
|
|
enoxaparin 30 mg/0.3 ml SDV syringe [VDMC]
|
Facility
|
IP
|
$26.50
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10607521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.55 |
| Max. Negotiated Rate |
$23.85 |
| Rate for Payer: Aetna of IA Commercial |
$23.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.85
|
| Rate for Payer: Cash Price |
$21.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.88
|
| Rate for Payer: Medical Associates Commercial |
$19.88
|
| Rate for Payer: Midlands Choice Commercial |
$18.55
|
| Rate for Payer: United Healthcare Commercial |
$23.85
|
|
|
enoxaparin 30 mg/0.3 ml SDV syringe [VDMC]
|
Facility
|
OP
|
$26.50
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10607521
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.24 |
| Max. Negotiated Rate |
$23.85 |
| Rate for Payer: Aetna of IA Commercial |
$23.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.85
|
| Rate for Payer: Aetna of IA Medicare |
$15.10
|
| Rate for Payer: Amerigroup Medicaid |
$13.37
|
| Rate for Payer: Amerigroup Medicare |
$13.38
|
| Rate for Payer: Cash Price |
$21.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.24
|
| Rate for Payer: Medical Associates Commercial |
$19.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.25
|
| Rate for Payer: Midlands Choice Commercial |
$18.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.45
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$13.44
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.88
|
| Rate for Payer: United Healthcare Commercial |
$23.85
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.64
|
|
|
enoxaparin 40 mg/0.4 mL SDV syringe [VDMC]
|
Facility
|
IP
|
$28.21
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10385764
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.75 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna of IA Commercial |
$25.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.39
|
| Rate for Payer: Cash Price |
$22.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.16
|
| Rate for Payer: Medical Associates Commercial |
$21.16
|
| Rate for Payer: Midlands Choice Commercial |
$19.75
|
| Rate for Payer: United Healthcare Commercial |
$25.39
|
|
|
enoxaparin 40 mg/0.4 mL SDV syringe [VDMC]
|
Facility
|
OP
|
$28.21
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10385764
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.10 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna of IA Commercial |
$25.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.39
|
| Rate for Payer: Aetna of IA Medicare |
$16.08
|
| Rate for Payer: Amerigroup Medicaid |
$14.24
|
| Rate for Payer: Amerigroup Medicare |
$14.25
|
| Rate for Payer: Cash Price |
$22.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.10
|
| Rate for Payer: Medical Associates Commercial |
$21.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.10
|
| Rate for Payer: Midlands Choice Commercial |
$19.75
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.32
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$14.31
|
| Rate for Payer: Oscar Health of IA Commercial |
$21.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.16
|
| Rate for Payer: United Healthcare Commercial |
$25.39
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.64
|
|
|
enoxaparin 60 mg/0.6 mL SDV syringe [VDMC]
|
Facility
|
IP
|
$37.85
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10385835
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$34.06 |
| Rate for Payer: Aetna of IA Commercial |
$34.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.06
|
| Rate for Payer: Cash Price |
$30.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.39
|
| Rate for Payer: Medical Associates Commercial |
$28.39
|
| Rate for Payer: Midlands Choice Commercial |
$26.50
|
| Rate for Payer: United Healthcare Commercial |
$34.06
|
|
|
enoxaparin 60 mg/0.6 mL SDV syringe [VDMC]
|
Facility
|
OP
|
$37.85
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10385835
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.92 |
| Max. Negotiated Rate |
$34.06 |
| Rate for Payer: Aetna of IA Commercial |
$34.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.06
|
| Rate for Payer: Aetna of IA Medicare |
$21.57
|
| Rate for Payer: Amerigroup Medicaid |
$19.10
|
| Rate for Payer: Amerigroup Medicare |
$19.11
|
| Rate for Payer: Cash Price |
$30.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.92
|
| Rate for Payer: Medical Associates Commercial |
$28.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.92
|
| Rate for Payer: Midlands Choice Commercial |
$26.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.21
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$19.20
|
| Rate for Payer: Oscar Health of IA Commercial |
$28.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$28.39
|
| Rate for Payer: United Healthcare Commercial |
$34.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.33
|
|
|
enoxaparin 80 mg/0.8 mL SDV syringe [VDMC]
|
Facility
|
OP
|
$38.68
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10385906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.33 |
| Max. Negotiated Rate |
$34.81 |
| Rate for Payer: Aetna of IA Commercial |
$34.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.81
|
| Rate for Payer: Aetna of IA Medicare |
$22.05
|
| Rate for Payer: Amerigroup Medicaid |
$19.52
|
| Rate for Payer: Amerigroup Medicare |
$19.53
|
| Rate for Payer: Cash Price |
$30.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$29.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.33
|
| Rate for Payer: Medical Associates Commercial |
$29.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.34
|
| Rate for Payer: Midlands Choice Commercial |
$27.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.63
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$19.62
|
| Rate for Payer: Oscar Health of IA Commercial |
$29.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$29.01
|
| Rate for Payer: United Healthcare Commercial |
$34.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.82
|
|
|
enoxaparin 80 mg/0.8 mL SDV syringe [VDMC]
|
Facility
|
IP
|
$38.68
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
10385906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.08 |
| Max. Negotiated Rate |
$34.81 |
| Rate for Payer: Aetna of IA Commercial |
$34.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.81
|
| Rate for Payer: Cash Price |
$30.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$29.01
|
| Rate for Payer: Medical Associates Commercial |
$29.01
|
| Rate for Payer: Midlands Choice Commercial |
$27.08
|
| Rate for Payer: United Healthcare Commercial |
$34.81
|
|
|
Enterovirus Detection PCR DMCL
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT 87498
|
| Hospital Charge Code |
8037855
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$68.82 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Aetna of IA Commercial |
$178.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.20
|
| Rate for Payer: Aetna of IA Medicare |
$112.86
|
| Rate for Payer: Amerigroup Medicaid |
$99.93
|
| Rate for Payer: Amerigroup Medicare |
$99.99
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$148.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$99.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$98.96
|
| Rate for Payer: Medical Associates Commercial |
$148.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$99.00
|
| Rate for Payer: Midlands Choice Commercial |
$138.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$100.48
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$100.43
|
| Rate for Payer: Oscar Health of IA Commercial |
$148.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$148.50
|
| Rate for Payer: United Healthcare Commercial |
$178.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$116.82
|
| Rate for Payer: Wellmark IA HMO |
$68.82
|
| Rate for Payer: Wellmark IA PPO |
$75.70
|
|
|
Enterovirus Detection PCR DMCL
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT 87498
|
| Hospital Charge Code |
8037855
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Aetna of IA Commercial |
$178.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.20
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$148.50
|
| Rate for Payer: Medical Associates Commercial |
$148.50
|
| Rate for Payer: Midlands Choice Commercial |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$178.20
|
|
|
ePHEDrine 50 mg/mL 1ml SDV [VDMC]
|
Facility
|
OP
|
$46.49
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15873673
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.24 |
| Max. Negotiated Rate |
$41.84 |
| Rate for Payer: Aetna of IA Commercial |
$41.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$41.84
|
| Rate for Payer: Aetna of IA Medicare |
$26.50
|
| Rate for Payer: Amerigroup Medicaid |
$23.46
|
| Rate for Payer: Amerigroup Medicare |
$23.48
|
| Rate for Payer: Cash Price |
$37.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$34.87
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.24
|
| Rate for Payer: Medical Associates Commercial |
$34.87
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.24
|
| Rate for Payer: Midlands Choice Commercial |
$32.54
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.59
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$23.58
|
| Rate for Payer: Oscar Health of IA Commercial |
$34.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.87
|
| Rate for Payer: United Healthcare Commercial |
$41.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$27.43
|
|
|
ePHEDrine 50 mg/mL 1ml SDV [VDMC]
|
Facility
|
IP
|
$46.49
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15873673
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.54 |
| Max. Negotiated Rate |
$41.84 |
| Rate for Payer: Aetna of IA Commercial |
$41.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$41.84
|
| Rate for Payer: Cash Price |
$37.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$34.87
|
| Rate for Payer: Medical Associates Commercial |
$34.87
|
| Rate for Payer: Midlands Choice Commercial |
$32.54
|
| Rate for Payer: United Healthcare Commercial |
$41.84
|
|
|
EPID INJECTION OF BLOOD PATCH
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
8059063
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$309.40 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: Aetna of IA Commercial |
$397.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$397.80
|
| Rate for Payer: Cash Price |
$353.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$331.50
|
| Rate for Payer: Medical Associates Commercial |
$331.50
|
| Rate for Payer: Midlands Choice Commercial |
$309.40
|
| Rate for Payer: United Healthcare Commercial |
$397.80
|
|
|
EPID INJECTION OF BLOOD PATCH
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
8059063
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$220.91 |
| Max. Negotiated Rate |
$1,487.44 |
| Rate for Payer: Aetna of IA Commercial |
$397.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$397.80
|
| Rate for Payer: Aetna of IA Medicare |
$251.94
|
| Rate for Payer: Amerigroup Medicaid |
$223.08
|
| Rate for Payer: Amerigroup Medicare |
$223.21
|
| Rate for Payer: Cash Price |
$353.60
|
| Rate for Payer: Cash Price |
$353.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$331.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$221.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$220.91
|
| Rate for Payer: Medical Associates Commercial |
$331.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$221.00
|
| Rate for Payer: Midlands Choice Commercial |
$309.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$224.32
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$224.18
|
| Rate for Payer: Oscar Health of IA Commercial |
$331.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$331.50
|
| Rate for Payer: United Healthcare Commercial |
$397.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$260.78
|
| Rate for Payer: Wellmark IA HMO |
$1,352.22
|
| Rate for Payer: Wellmark IA PPO |
$1,487.44
|
|
|
EPIDURAL BLOCK-CERVICAL/THORACIC SPINE
|
Professional
|
Both
|
$554.00
|
|
|
Service Code
|
CPT 62320
|
| Hospital Charge Code |
8101309
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$90.48 |
| Max. Negotiated Rate |
$387.80 |
| Rate for Payer: Aetna of IA Medicare |
$90.48
|
| Rate for Payer: Amerigroup Medicaid |
$93.56
|
| Rate for Payer: Cash Price |
$443.20
|
| Rate for Payer: Cash Price |
$443.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$108.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$92.29
|
| Rate for Payer: Medical Associates Commercial |
$171.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.48
|
| Rate for Payer: Midlands Choice Commercial |
$387.80
|
| Rate for Payer: Oscar Health of IA Commercial |
$156.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$135.72
|
|
|
EPIDURAL DRUG MGMT/PAINCONTINUOUS ADMIN
|
Facility
|
IP
|
$1,080.00
|
|
| Hospital Charge Code |
8059057
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$756.00 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna of IA Commercial |
$972.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$972.00
|
| Rate for Payer: Cash Price |
$864.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$810.00
|
| Rate for Payer: Medical Associates Commercial |
$810.00
|
| Rate for Payer: Midlands Choice Commercial |
$756.00
|
| Rate for Payer: United Healthcare Commercial |
$972.00
|
|
|
EPIDURAL DRUG MGMT/PAINCONTINUOUS ADMIN
|
Facility
|
OP
|
$1,080.00
|
|
| Hospital Charge Code |
8059057
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$539.78 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna of IA Commercial |
$972.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$972.00
|
| Rate for Payer: Aetna of IA Medicare |
$615.60
|
| Rate for Payer: Amerigroup Medicaid |
$545.08
|
| Rate for Payer: Amerigroup Medicare |
$545.40
|
| Rate for Payer: Cash Price |
$864.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$810.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$540.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$539.78
|
| Rate for Payer: Medical Associates Commercial |
$810.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$540.00
|
| Rate for Payer: Midlands Choice Commercial |
$756.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$548.10
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$547.78
|
| Rate for Payer: Oscar Health of IA Commercial |
$810.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$810.00
|
| Rate for Payer: United Healthcare Commercial |
$972.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$637.20
|
|
|
EPINEPHrine 0.3 mg Kit [VDMC]
|
Facility
|
IP
|
$544.30
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
11223910
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$381.01 |
| Max. Negotiated Rate |
$489.87 |
| Rate for Payer: Aetna of IA Commercial |
$489.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$489.87
|
| Rate for Payer: Cash Price |
$435.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$408.22
|
| Rate for Payer: Medical Associates Commercial |
$408.22
|
| Rate for Payer: Midlands Choice Commercial |
$381.01
|
| Rate for Payer: United Healthcare Commercial |
$489.87
|
|
|
EPINEPHrine 0.3 mg Kit [VDMC]
|
Facility
|
OP
|
$544.30
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
11223910
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$272.04 |
| Max. Negotiated Rate |
$489.87 |
| Rate for Payer: Aetna of IA Commercial |
$489.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$489.87
|
| Rate for Payer: Aetna of IA Medicare |
$310.25
|
| Rate for Payer: Amerigroup Medicaid |
$274.71
|
| Rate for Payer: Amerigroup Medicare |
$274.87
|
| Rate for Payer: Cash Price |
$435.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$408.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$272.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$272.04
|
| Rate for Payer: Medical Associates Commercial |
$408.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$272.15
|
| Rate for Payer: Midlands Choice Commercial |
$381.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$276.23
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$276.07
|
| Rate for Payer: Oscar Health of IA Commercial |
$408.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$408.22
|
| Rate for Payer: United Healthcare Commercial |
$489.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$321.14
|
|
|
EPINEPHrine 0.3mL Syringe SDV [VDMC]
|
Facility
|
IP
|
$71.79
|
|
|
Service Code
|
NDC 99999-9061-00
|
| Hospital Charge Code |
12362767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$50.25 |
| Max. Negotiated Rate |
$64.61 |
| Rate for Payer: Aetna of IA Commercial |
$64.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.61
|
| Rate for Payer: Cash Price |
$57.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.84
|
| Rate for Payer: Medical Associates Commercial |
$53.84
|
| Rate for Payer: Midlands Choice Commercial |
$50.25
|
| Rate for Payer: United Healthcare Commercial |
$64.61
|
|
|
EPINEPHrine 0.3mL Syringe SDV [VDMC]
|
Facility
|
OP
|
$71.79
|
|
|
Service Code
|
NDC 99999-9061-00
|
| Hospital Charge Code |
12362767
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$64.61 |
| Rate for Payer: Aetna of IA Commercial |
$64.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.61
|
| Rate for Payer: Aetna of IA Medicare |
$40.92
|
| Rate for Payer: Amerigroup Medicaid |
$36.23
|
| Rate for Payer: Amerigroup Medicare |
$36.25
|
| Rate for Payer: Cash Price |
$57.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$35.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.88
|
| Rate for Payer: Medical Associates Commercial |
$53.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$35.90
|
| Rate for Payer: Midlands Choice Commercial |
$50.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.43
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$36.41
|
| Rate for Payer: Oscar Health of IA Commercial |
$53.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$53.84
|
| Rate for Payer: United Healthcare Commercial |
$64.61
|
| Rate for Payer: United Healthcare Managed Medicare |
$42.36
|
|
|
EPINEPHrine 1 mg/mL 1ml vial SDV [VDMC]
|
Facility
|
IP
|
$108.27
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
11219984
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$75.79 |
| Max. Negotiated Rate |
$97.44 |
| Rate for Payer: Aetna of IA Commercial |
$97.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.44
|
| Rate for Payer: Cash Price |
$86.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.20
|
| Rate for Payer: Medical Associates Commercial |
$81.20
|
| Rate for Payer: Midlands Choice Commercial |
$75.79
|
| Rate for Payer: United Healthcare Commercial |
$97.44
|
|
|
EPINEPHrine 1 mg/mL 1ml vial SDV [VDMC]
|
Facility
|
OP
|
$108.27
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
11219984
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.11 |
| Max. Negotiated Rate |
$97.44 |
| Rate for Payer: Aetna of IA Commercial |
$97.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.44
|
| Rate for Payer: Aetna of IA Medicare |
$61.71
|
| Rate for Payer: Amerigroup Medicaid |
$54.64
|
| Rate for Payer: Amerigroup Medicare |
$54.68
|
| Rate for Payer: Cash Price |
$86.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.14
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$54.11
|
| Rate for Payer: Medical Associates Commercial |
$81.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.14
|
| Rate for Payer: Midlands Choice Commercial |
$75.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.95
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$54.91
|
| Rate for Payer: Oscar Health of IA Commercial |
$81.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.20
|
| Rate for Payer: United Healthcare Commercial |
$97.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.88
|
|
|
EPINEPHrine 1 mg/mL 30ml Inj MDV [VDMC]
|
Facility
|
OP
|
$645.48
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386241
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$322.61 |
| Max. Negotiated Rate |
$580.93 |
| Rate for Payer: Aetna of IA Commercial |
$580.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$580.93
|
| Rate for Payer: Aetna of IA Medicare |
$367.92
|
| Rate for Payer: Amerigroup Medicaid |
$325.77
|
| Rate for Payer: Amerigroup Medicare |
$325.97
|
| Rate for Payer: Cash Price |
$516.38
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$484.11
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$322.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$322.61
|
| Rate for Payer: Medical Associates Commercial |
$484.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$322.74
|
| Rate for Payer: Midlands Choice Commercial |
$451.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$327.58
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$327.39
|
| Rate for Payer: Oscar Health of IA Commercial |
$484.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$484.11
|
| Rate for Payer: United Healthcare Commercial |
$580.93
|
| Rate for Payer: United Healthcare Managed Medicare |
$380.83
|
|
