|
guaiFENesin 200 mg/10 mL Liq 10ml UD [VDMC]
|
Facility
|
IP
|
$8.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11221333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna of IA Commercial |
$7.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.45
|
| Rate for Payer: Cash Price |
$6.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.21
|
| Rate for Payer: Medical Associates Commercial |
$6.21
|
| Rate for Payer: Midlands Choice Commercial |
$5.80
|
| Rate for Payer: United Healthcare Commercial |
$7.45
|
|
|
guaiFENesin 200 mg/10 mL Liq 10ml UD [VDMC]
|
Facility
|
OP
|
$8.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11221333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna of IA Commercial |
$7.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.45
|
| Rate for Payer: Aetna of IA Medicare |
$4.72
|
| Rate for Payer: Amerigroup Medicaid |
$4.78
|
| Rate for Payer: Amerigroup Medicare |
$3.76
|
| Rate for Payer: Cash Price |
$6.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.21
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.73
|
| Rate for Payer: Medical Associates Commercial |
$6.21
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.73
|
| Rate for Payer: Midlands Choice Commercial |
$5.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.29
|
| Rate for Payer: United Healthcare Commercial |
$7.45
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.89
|
|
|
guaiFENesin 600 mg ER Tab [VDMC]
|
Facility
|
IP
|
$2.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10392793
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna of IA Commercial |
$2.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.06
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.71
|
| Rate for Payer: Medical Associates Commercial |
$1.71
|
| Rate for Payer: Midlands Choice Commercial |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$2.06
|
|
|
guaiFENesin 600 mg ER Tab [VDMC]
|
Facility
|
OP
|
$2.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10392793
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna of IA Commercial |
$2.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.06
|
| Rate for Payer: Aetna of IA Medicare |
$1.30
|
| Rate for Payer: Amerigroup Medicaid |
$1.32
|
| Rate for Payer: Amerigroup Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.03
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.31
|
| Rate for Payer: Medical Associates Commercial |
$1.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.03
|
| Rate for Payer: Midlands Choice Commercial |
$1.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$2.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.35
|
|
|
guaiFENesin-codeine 100 mg-10mg/5 mL Oral Syrup 5 mL [VDMC]
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10379162
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Aetna of IA Commercial |
$3.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.51
|
| Rate for Payer: Aetna of IA Medicare |
$2.22
|
| Rate for Payer: Amerigroup Medicaid |
$2.25
|
| Rate for Payer: Amerigroup Medicare |
$1.77
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.93
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.76
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.23
|
| Rate for Payer: Medical Associates Commercial |
$2.93
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.76
|
| Rate for Payer: Midlands Choice Commercial |
$2.73
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.02
|
| Rate for Payer: United Healthcare Commercial |
$3.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.30
|
|
|
guaiFENesin-codeine 100 mg-10mg/5 mL Oral Syrup 5 mL [VDMC]
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10379162
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Aetna of IA Commercial |
$3.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.51
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.93
|
| Rate for Payer: Medical Associates Commercial |
$2.93
|
| Rate for Payer: Midlands Choice Commercial |
$2.73
|
| Rate for Payer: United Healthcare Commercial |
$3.51
|
|
|
guaiFENesin-dextromethorphan100 mg-10 mg/5 mL Oral Liq 5 mL [VDMC]
|
Facility
|
OP
|
$3.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of IA Commercial |
$3.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.20
|
| Rate for Payer: Aetna of IA Medicare |
$2.03
|
| Rate for Payer: Amerigroup Medicaid |
$2.05
|
| Rate for Payer: Amerigroup Medicare |
$1.62
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.67
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.03
|
| Rate for Payer: Medical Associates Commercial |
$2.67
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.60
|
| Rate for Payer: Midlands Choice Commercial |
$2.49
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$3.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.10
|
|
|
guaiFENesin-dextromethorphan100 mg-10 mg/5 mL Oral Liq 5 mL [VDMC]
|
Facility
|
IP
|
$3.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10382035
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of IA Commercial |
$3.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.20
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.67
|
| Rate for Payer: Medical Associates Commercial |
$2.67
|
| Rate for Payer: Midlands Choice Commercial |
$2.49
|
| Rate for Payer: United Healthcare Commercial |
$3.20
|
|
|
GUIDEWIRE .035 X 4
|
Facility
|
OP
|
$29.00
|
|
| Hospital Charge Code |
8046429
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$26.10 |
| Rate for Payer: Aetna of IA Commercial |
$26.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.10
|
| Rate for Payer: Aetna of IA Medicare |
$16.53
|
| Rate for Payer: Amerigroup Medicaid |
$16.73
|
| Rate for Payer: Amerigroup Medicare |
$13.18
|
| Rate for Payer: Cash Price |
$23.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.56
|
| Rate for Payer: Medical Associates Commercial |
$21.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.05
|
| Rate for Payer: Midlands Choice Commercial |
$20.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.01
|
| Rate for Payer: United Healthcare Commercial |
$26.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.11
|
|
|
GUIDEWIRE .035 X 4
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
8046429
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$26.10 |
| Rate for Payer: Aetna of IA Commercial |
$26.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.10
|
| Rate for Payer: Cash Price |
$23.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.75
|
| Rate for Payer: Medical Associates Commercial |
$21.75
|
| Rate for Payer: Midlands Choice Commercial |
$20.30
|
| Rate for Payer: United Healthcare Commercial |
$26.10
|
|
|
GUIDEWIRE .045 X 6''
|
Facility
|
IP
|
$17.00
|
|
| Hospital Charge Code |
8046463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of IA Commercial |
$15.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.30
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.75
|
| Rate for Payer: Medical Associates Commercial |
$12.75
|
| Rate for Payer: Midlands Choice Commercial |
$11.90
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
|
|
GUIDEWIRE .045 X 6''
|
Facility
|
OP
|
$17.00
|
|
| Hospital Charge Code |
8046463
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of IA Commercial |
$15.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.30
|
| Rate for Payer: Aetna of IA Medicare |
$9.69
|
| Rate for Payer: Amerigroup Medicaid |
$9.81
|
| Rate for Payer: Amerigroup Medicare |
$7.73
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.71
|
| Rate for Payer: Medical Associates Commercial |
$12.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.65
|
| Rate for Payer: Midlands Choice Commercial |
$11.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.80
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.03
|
|
|
GUIDE WIRE,.062''
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
8047219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna of IA Commercial |
$6.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.30
|
| Rate for Payer: Aetna of IA Medicare |
$3.99
|
| Rate for Payer: Amerigroup Medicaid |
$4.04
|
| Rate for Payer: Amerigroup Medicare |
$3.18
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.25
|
| 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 |
$4.00
|
| Rate for Payer: Medical Associates Commercial |
$5.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.15
|
| Rate for Payer: Midlands Choice Commercial |
$4.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.62
|
| Rate for Payer: United Healthcare Commercial |
$6.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.13
|
|
|
GUIDE WIRE,.062''
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
8047219
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna of IA Commercial |
$6.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.30
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.25
|
| Rate for Payer: Medical Associates Commercial |
$5.25
|
| Rate for Payer: Midlands Choice Commercial |
$4.90
|
| Rate for Payer: United Healthcare Commercial |
$6.30
|
|
|
GUIDE WIRE,.094'' 2.4MM X8''
|
Facility
|
OP
|
$18.00
|
|
| Hospital Charge Code |
8047264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of IA Commercial |
$16.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.20
|
| Rate for Payer: Aetna of IA Medicare |
$10.26
|
| Rate for Payer: Amerigroup Medicaid |
$10.38
|
| Rate for Payer: Amerigroup Medicare |
$8.18
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.28
|
| Rate for Payer: Medical Associates Commercial |
$13.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.10
|
| Rate for Payer: Midlands Choice Commercial |
$12.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.32
|
| Rate for Payer: United Healthcare Commercial |
$16.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.62
|
|
|
GUIDE WIRE,.094'' 2.4MM X8''
|
Facility
|
IP
|
$18.00
|
|
| Hospital Charge Code |
8047264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of IA Commercial |
$16.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.20
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.50
|
| Rate for Payer: Medical Associates Commercial |
$13.50
|
| Rate for Payer: Midlands Choice Commercial |
$12.60
|
| Rate for Payer: United Healthcare Commercial |
$16.20
|
|
|
GUIDE WIRE ASNIS III 1.4X150MM
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
8046966
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$29.40 |
| 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: Cash Price |
$33.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.50
|
| Rate for Payer: Medical Associates Commercial |
$31.50
|
| Rate for Payer: Midlands Choice Commercial |
$29.40
|
| Rate for Payer: United Healthcare Commercial |
$37.80
|
|
|
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 |
$21.74
|
| 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
|
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 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 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 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 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
|
|
