|
GUIDE WIRE ASNIS III 1.4X150MM
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
8046966
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$37.80 |
| Rate for Payer: Aetna of IA Commercial |
$37.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.80
|
| Rate for Payer: Aetna of IA Medicare |
$23.94
|
| Rate for Payer: Amerigroup Medicaid |
$24.23
|
| Rate for Payer: Amerigroup Medicare |
$19.09
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.99
|
| Rate for Payer: Medical Associates Commercial |
$31.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.90
|
| Rate for Payer: Midlands Choice Commercial |
$29.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.73
|
| Rate for Payer: United Healthcare Commercial |
$37.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.78
|
|
|
GUIDEWIRE BALLTIP 3.0X800MM
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$176.40 |
| Rate for Payer: Aetna of IA Commercial |
$176.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$176.40
|
| Rate for Payer: Aetna of IA Medicare |
$111.72
|
| Rate for Payer: Amerigroup Medicaid |
$113.05
|
| Rate for Payer: Amerigroup Medicare |
$89.08
|
| Rate for Payer: Cash Price |
$156.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$147.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$88.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$111.96
|
| Rate for Payer: Medical Associates Commercial |
$147.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$88.20
|
| Rate for Payer: Midlands Choice Commercial |
$137.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$113.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$101.43
|
| Rate for Payer: United Healthcare Commercial |
$176.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$115.64
|
|
|
GUIDEWIRE BALLTIP 3.0X800MM
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046329
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$176.40 |
| Rate for Payer: Aetna of IA Commercial |
$176.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$176.40
|
| Rate for Payer: Cash Price |
$156.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$147.00
|
| Rate for Payer: Medical Associates Commercial |
$147.00
|
| Rate for Payer: Midlands Choice Commercial |
$137.20
|
| Rate for Payer: United Healthcare Commercial |
$176.40
|
|
|
GUIDEWIRE BENTSON .035X150
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046312
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$29.70 |
| Rate for Payer: Aetna of IA Commercial |
$29.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.70
|
| Rate for Payer: Aetna of IA Medicare |
$18.81
|
| Rate for Payer: Amerigroup Medicaid |
$19.03
|
| Rate for Payer: Amerigroup Medicare |
$15.00
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.85
|
| Rate for Payer: Medical Associates Commercial |
$24.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.85
|
| Rate for Payer: Midlands Choice Commercial |
$23.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.08
|
| Rate for Payer: United Healthcare Commercial |
$29.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.47
|
|
|
GUIDEWIRE BENTSON .035X150
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046312
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$29.70 |
| Rate for Payer: Aetna of IA Commercial |
$29.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.70
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.75
|
| Rate for Payer: Medical Associates Commercial |
$24.75
|
| Rate for Payer: Midlands Choice Commercial |
$23.10
|
| Rate for Payer: United Healthcare Commercial |
$29.70
|
|
|
GUIDEWIRE EZ GLIDER ANGLE TIP
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8026115
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of IA Commercial |
$54.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.00
|
| Rate for Payer: Aetna of IA Medicare |
$34.20
|
| Rate for Payer: Amerigroup Medicaid |
$34.61
|
| Rate for Payer: Amerigroup Medicare |
$27.27
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$34.27
|
| Rate for Payer: Medical Associates Commercial |
$45.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.00
|
| Rate for Payer: Midlands Choice Commercial |
$42.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$34.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.05
|
| Rate for Payer: United Healthcare Commercial |
$54.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.40
|
|
|
GUIDEWIRE EZ GLIDER ANGLE TIP
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8026115
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of IA Commercial |
$54.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.00
|
| Rate for Payer: Medical Associates Commercial |
$45.00
|
| Rate for Payer: Midlands Choice Commercial |
$42.00
|
| Rate for Payer: United Healthcare Commercial |
$54.00
|
|
|
GUIDEWIRE E-Z GLIDER STRAIGHT TIP
|
Facility
|
IP
|
$522.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$365.40 |
| Max. Negotiated Rate |
$469.80 |
| Rate for Payer: Aetna of IA Commercial |
$469.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$469.80
|
| Rate for Payer: Cash Price |
$417.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$391.50
|
| Rate for Payer: Medical Associates Commercial |
$391.50
|
| Rate for Payer: Midlands Choice Commercial |
$365.40
|
| Rate for Payer: United Healthcare Commercial |
$469.80
|
|
|
GUIDEWIRE E-Z GLIDER STRAIGHT TIP
|
Facility
|
OP
|
$522.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$234.90 |
| Max. Negotiated Rate |
$469.80 |
| Rate for Payer: Aetna of IA Commercial |
$469.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$469.80
|
| Rate for Payer: Aetna of IA Medicare |
$297.54
|
| Rate for Payer: Amerigroup Medicaid |
$301.09
|
| Rate for Payer: Amerigroup Medicare |
$237.25
|
| Rate for Payer: Cash Price |
$417.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$391.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$234.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$298.17
|
| Rate for Payer: Medical Associates Commercial |
$391.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$234.90
|
| Rate for Payer: Midlands Choice Commercial |
$365.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$302.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$270.13
|
| Rate for Payer: United Healthcare Commercial |
$469.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$307.98
|
|
|
GUIDEWIRE KNEE BALLTIP 3.0X800MM
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$207.90 |
| Rate for Payer: Aetna of IA Commercial |
$207.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.90
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$173.25
|
| Rate for Payer: Medical Associates Commercial |
$173.25
|
| Rate for Payer: Midlands Choice Commercial |
$161.70
|
| Rate for Payer: United Healthcare Commercial |
$207.90
|
|
|
GUIDEWIRE KNEE BALLTIP 3.0X800MM
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046330
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.95 |
| Max. Negotiated Rate |
$207.90 |
| Rate for Payer: Aetna of IA Commercial |
$207.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.90
|
| Rate for Payer: Aetna of IA Medicare |
$131.67
|
| Rate for Payer: Amerigroup Medicaid |
$133.24
|
| Rate for Payer: Amerigroup Medicare |
$104.99
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$173.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$103.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$131.95
|
| Rate for Payer: Medical Associates Commercial |
$173.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$103.95
|
| Rate for Payer: Midlands Choice Commercial |
$161.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$133.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$119.54
|
| Rate for Payer: United Healthcare Commercial |
$207.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$136.29
|
|
|
GUIDEWIRE PARTIALLY THREADED
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046428
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Aetna of IA Commercial |
$30.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.60
|
| Rate for Payer: Cash Price |
$27.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.50
|
| Rate for Payer: Medical Associates Commercial |
$25.50
|
| Rate for Payer: Midlands Choice Commercial |
$23.80
|
| Rate for Payer: United Healthcare Commercial |
$30.60
|
|
|
GUIDEWIRE PARTIALLY THREADED
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046428
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Aetna of IA Commercial |
$30.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.60
|
| Rate for Payer: Aetna of IA Medicare |
$19.38
|
| Rate for Payer: Amerigroup Medicaid |
$19.61
|
| Rate for Payer: Amerigroup Medicare |
$15.45
|
| Rate for Payer: Cash Price |
$27.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.42
|
| Rate for Payer: Medical Associates Commercial |
$25.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.30
|
| Rate for Payer: Midlands Choice Commercial |
$23.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.59
|
| Rate for Payer: United Healthcare Commercial |
$30.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$20.06
|
|
|
GUIDEWIRE SUPER STIFF .035 AMPLATZ
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of IA Commercial |
$55.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.80
|
| Rate for Payer: Aetna of IA Medicare |
$35.34
|
| Rate for Payer: Amerigroup Medicaid |
$35.76
|
| Rate for Payer: Amerigroup Medicare |
$28.18
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.41
|
| Rate for Payer: Medical Associates Commercial |
$46.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.90
|
| Rate for Payer: Midlands Choice Commercial |
$43.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.09
|
| Rate for Payer: United Healthcare Commercial |
$55.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.58
|
|
|
GUIDEWIRE SUPER STIFF .035 AMPLATZ
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
8046320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of IA Commercial |
$55.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.80
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.50
|
| Rate for Payer: Medical Associates Commercial |
$46.50
|
| Rate for Payer: Midlands Choice Commercial |
$43.40
|
| Rate for Payer: United Healthcare Commercial |
$55.80
|
|
|
haemophilus b conjugate (PRP-OMP) vaccine 7.5 mcg-125 mcg/0.5 mL Sus[VDMC]
|
Facility
|
OP
|
$70.09
|
|
|
Service Code
|
HCPCS 90647
|
| Hospital Charge Code |
12601118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.54 |
| Max. Negotiated Rate |
$63.08 |
| Rate for Payer: Aetna of IA Commercial |
$63.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.08
|
| Rate for Payer: Aetna of IA Medicare |
$39.95
|
| Rate for Payer: Amerigroup Medicaid |
$40.43
|
| Rate for Payer: Amerigroup Medicare |
$31.86
|
| Rate for Payer: Cash Price |
$56.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.57
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40.04
|
| Rate for Payer: Medical Associates Commercial |
$52.57
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.54
|
| Rate for Payer: Midlands Choice Commercial |
$49.06
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$40.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.27
|
| Rate for Payer: United Healthcare Commercial |
$63.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$41.35
|
|
|
haemophilus b conjugate (PRP-OMP) vaccine 7.5 mcg-125 mcg/0.5 mL Sus[VDMC]
|
Facility
|
IP
|
$70.09
|
|
|
Service Code
|
HCPCS 90647
|
| Hospital Charge Code |
12601118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.06 |
| Max. Negotiated Rate |
$63.08 |
| Rate for Payer: Aetna of IA Commercial |
$63.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.08
|
| Rate for Payer: Cash Price |
$56.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$52.57
|
| Rate for Payer: Medical Associates Commercial |
$52.57
|
| Rate for Payer: Midlands Choice Commercial |
$49.06
|
| Rate for Payer: United Healthcare Commercial |
$63.08
|
|
|
haemophilus b conjugate (PRP-T) vaccine - Pow SDV [VDMC]
|
Facility
|
IP
|
$40.79
|
|
|
Service Code
|
HCPCS 90648
|
| Hospital Charge Code |
12950205
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.55 |
| Max. Negotiated Rate |
$36.71 |
| Rate for Payer: Aetna of IA Commercial |
$36.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.71
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.59
|
| Rate for Payer: Medical Associates Commercial |
$30.59
|
| Rate for Payer: Midlands Choice Commercial |
$28.55
|
| Rate for Payer: United Healthcare Commercial |
$36.71
|
|
|
haemophilus b conjugate (PRP-T) vaccine - Pow SDV [VDMC]
|
Facility
|
OP
|
$40.79
|
|
|
Service Code
|
HCPCS 90648
|
| Hospital Charge Code |
12950205
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$36.71 |
| Rate for Payer: Aetna of IA Commercial |
$36.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.71
|
| Rate for Payer: Aetna of IA Medicare |
$23.25
|
| Rate for Payer: Amerigroup Medicaid |
$23.53
|
| Rate for Payer: Amerigroup Medicare |
$18.54
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.59
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.30
|
| Rate for Payer: Medical Associates Commercial |
$30.59
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.35
|
| Rate for Payer: Midlands Choice Commercial |
$28.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.11
|
| Rate for Payer: United Healthcare Commercial |
$36.71
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.06
|
|
|
haloperidol 0.5 mg Tab [VDMC]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10392862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of IA Commercial |
$1.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.75
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.46
|
| Rate for Payer: Medical Associates Commercial |
$1.46
|
| Rate for Payer: Midlands Choice Commercial |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$1.75
|
|
|
haloperidol 0.5 mg Tab [VDMC]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10392862
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of IA Commercial |
$1.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.75
|
| Rate for Payer: Aetna of IA Medicare |
$1.11
|
| Rate for Payer: Amerigroup Medicaid |
$1.12
|
| Rate for Payer: Amerigroup Medicare |
$0.89
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.46
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.11
|
| Rate for Payer: Medical Associates Commercial |
$1.46
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.88
|
| Rate for Payer: Midlands Choice Commercial |
$1.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$1.75
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.15
|
|
|
haloperidol 2 mg/mL 15ml Con [VDMC]
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11220983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna of IA Commercial |
$50.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.40
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.00
|
| Rate for Payer: Medical Associates Commercial |
$42.00
|
| Rate for Payer: Midlands Choice Commercial |
$39.20
|
| Rate for Payer: United Healthcare Commercial |
$50.40
|
|
|
haloperidol 2 mg/mL 15ml Con [VDMC]
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11220983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna of IA Commercial |
$50.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.40
|
| Rate for Payer: Aetna of IA Medicare |
$31.92
|
| Rate for Payer: Amerigroup Medicaid |
$32.30
|
| Rate for Payer: Amerigroup Medicare |
$25.45
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$25.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.99
|
| Rate for Payer: Medical Associates Commercial |
$42.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.20
|
| Rate for Payer: Midlands Choice Commercial |
$39.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$28.98
|
| Rate for Payer: United Healthcare Commercial |
$50.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.04
|
|
|
haloperidol 5 mg/mL 1 ml Inj SDV [VDMC]
|
Facility
|
OP
|
$22.91
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
10393000
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.31 |
| Max. Negotiated Rate |
$20.62 |
| Rate for Payer: Aetna of IA Commercial |
$20.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.62
|
| Rate for Payer: Aetna of IA Medicare |
$13.06
|
| Rate for Payer: Amerigroup Medicaid |
$13.22
|
| Rate for Payer: Amerigroup Medicare |
$10.41
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.09
|
| Rate for Payer: Medical Associates Commercial |
$17.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.31
|
| Rate for Payer: Midlands Choice Commercial |
$16.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.86
|
| Rate for Payer: United Healthcare Commercial |
$20.62
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.52
|
|
|
haloperidol 5 mg/mL 1 ml Inj SDV [VDMC]
|
Facility
|
IP
|
$22.91
|
|
|
Service Code
|
HCPCS J1630
|
| Hospital Charge Code |
10393000
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.04 |
| Max. Negotiated Rate |
$20.62 |
| Rate for Payer: Aetna of IA Commercial |
$20.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.62
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.19
|
| Rate for Payer: Medical Associates Commercial |
$17.19
|
| Rate for Payer: Midlands Choice Commercial |
$16.04
|
| Rate for Payer: United Healthcare Commercial |
$20.62
|
|
