|
lidocaine 2% 200mg/10 mL MDV
|
Facility
IP
|
$26.92
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43701617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$24.23 |
| Rate for Payer: Aetna of IA Commercial |
$24.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.23
|
| Rate for Payer: Cash Price |
$21.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.19
|
| Rate for Payer: Medical Associates Commercial |
$20.19
|
| Rate for Payer: Midlands Choice Commercial |
$18.84
|
| Rate for Payer: United Healthcare Commercial |
$24.23
|
|
|
lidocaine 2% 400mg/20 mL MDV
|
Facility
IP
|
$25.49
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43701606
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.84 |
| Max. Negotiated Rate |
$22.94 |
| Rate for Payer: Aetna of IA Commercial |
$22.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.94
|
| Rate for Payer: Cash Price |
$20.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.12
|
| Rate for Payer: Medical Associates Commercial |
$19.12
|
| Rate for Payer: Midlands Choice Commercial |
$17.84
|
| Rate for Payer: United Healthcare Commercial |
$22.94
|
|
|
lidocaine 2% 400mg/20 mL MDV
|
Facility
OP
|
$25.49
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43701606
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$22.94 |
| Rate for Payer: Aetna of IA Commercial |
$22.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.94
|
| Rate for Payer: Aetna of IA Medicare |
$14.53
|
| Rate for Payer: Amerigroup Medicaid |
$12.86
|
| Rate for Payer: Amerigroup Medicare |
$12.87
|
| Rate for Payer: Cash Price |
$20.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.74
|
| Rate for Payer: Medical Associates Commercial |
$19.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.74
|
| Rate for Payer: Midlands Choice Commercial |
$17.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.12
|
| Rate for Payer: United Healthcare Commercial |
$22.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.04
|
|
|
lidocaine 4% PF 5 ML SDV
|
Facility
IP
|
$32.51
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43721504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$29.26 |
| Rate for Payer: Aetna of IA Commercial |
$29.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.26
|
| Rate for Payer: Cash Price |
$26.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.38
|
| Rate for Payer: Medical Associates Commercial |
$24.38
|
| Rate for Payer: Midlands Choice Commercial |
$22.76
|
| Rate for Payer: United Healthcare Commercial |
$29.26
|
|
|
lidocaine 4% PF 5 ML SDV
|
Facility
OP
|
$32.51
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43721504
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$29.26 |
| Rate for Payer: Aetna of IA Commercial |
$29.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.26
|
| Rate for Payer: Aetna of IA Medicare |
$18.53
|
| Rate for Payer: Amerigroup Medicaid |
$16.41
|
| Rate for Payer: Amerigroup Medicare |
$16.42
|
| Rate for Payer: Cash Price |
$26.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$16.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.25
|
| Rate for Payer: Medical Associates Commercial |
$24.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.26
|
| Rate for Payer: Midlands Choice Commercial |
$22.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.38
|
| Rate for Payer: United Healthcare Commercial |
$29.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.18
|
|
|
lidocaine emergency syringe 100mg/5ml
|
Facility
IP
|
$42.19
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43701618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.53 |
| Max. Negotiated Rate |
$37.97 |
| Rate for Payer: Aetna of IA Commercial |
$37.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.97
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.64
|
| Rate for Payer: Medical Associates Commercial |
$31.64
|
| Rate for Payer: Midlands Choice Commercial |
$29.53
|
| Rate for Payer: United Healthcare Commercial |
$37.97
|
|
|
lidocaine emergency syringe 100mg/5ml
|
Facility
OP
|
$42.19
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43701618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.09 |
| Max. Negotiated Rate |
$37.97 |
| Rate for Payer: Aetna of IA Commercial |
$37.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.97
|
| Rate for Payer: Aetna of IA Medicare |
$24.05
|
| Rate for Payer: Amerigroup Medicaid |
$21.29
|
| Rate for Payer: Amerigroup Medicare |
$21.31
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.09
|
| Rate for Payer: Medical Associates Commercial |
$31.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.10
|
| Rate for Payer: Midlands Choice Commercial |
$29.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.41
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.64
|
| Rate for Payer: United Healthcare Commercial |
$37.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.89
|
|
|
lidocaine-epinephrine 1:100000-1% 500mg/50ml MDV inj
|
Facility
IP
|
$56.93
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.85 |
| Max. Negotiated Rate |
$51.24 |
| Rate for Payer: Aetna of IA Commercial |
$51.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.24
|
| Rate for Payer: Cash Price |
$45.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.70
|
| Rate for Payer: Medical Associates Commercial |
$42.70
|
| Rate for Payer: Midlands Choice Commercial |
$39.85
|
| Rate for Payer: United Healthcare Commercial |
$51.24
|
|
|
lidocaine-epinephrine 1:100000-1% 500mg/50ml MDV inj
|
Facility
OP
|
$56.93
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.45 |
| Max. Negotiated Rate |
$51.24 |
| Rate for Payer: Aetna of IA Commercial |
$51.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.24
|
| Rate for Payer: Aetna of IA Medicare |
$32.45
|
| Rate for Payer: Amerigroup Medicaid |
$28.73
|
| Rate for Payer: Amerigroup Medicare |
$28.75
|
| Rate for Payer: Cash Price |
$45.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.45
|
| Rate for Payer: Medical Associates Commercial |
$42.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.46
|
| Rate for Payer: Midlands Choice Commercial |
$39.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$28.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.70
|
| Rate for Payer: United Healthcare Commercial |
$51.24
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.59
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj 10 mL MDV
|
Facility
OP
|
$26.44
|
|
|
Service Code
|
CPT CN204
|
| Hospital Charge Code |
43700462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.21 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna of IA Commercial |
$23.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.80
|
| Rate for Payer: Aetna of IA Medicare |
$15.07
|
| Rate for Payer: Amerigroup Medicaid |
$13.34
|
| Rate for Payer: Amerigroup Medicare |
$13.35
|
| Rate for Payer: Cash Price |
$21.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.83
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.21
|
| Rate for Payer: Medical Associates Commercial |
$19.83
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.22
|
| Rate for Payer: Midlands Choice Commercial |
$18.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.83
|
| Rate for Payer: United Healthcare Commercial |
$23.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.60
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj 10 mL MDV
|
Facility
IP
|
$26.44
|
|
|
Service Code
|
CPT CN204
|
| Hospital Charge Code |
43700462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.51 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna of IA Commercial |
$23.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.80
|
| Rate for Payer: Cash Price |
$21.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.83
|
| Rate for Payer: Medical Associates Commercial |
$19.83
|
| Rate for Payer: Midlands Choice Commercial |
$18.51
|
| Rate for Payer: United Healthcare Commercial |
$23.80
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj MDV 20 mL
|
Facility
OP
|
$35.86
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702208
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.92 |
| Max. Negotiated Rate |
$32.27 |
| Rate for Payer: Aetna of IA Commercial |
$32.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.27
|
| Rate for Payer: Aetna of IA Medicare |
$20.44
|
| Rate for Payer: Amerigroup Medicaid |
$18.10
|
| Rate for Payer: Amerigroup Medicare |
$18.11
|
| Rate for Payer: Cash Price |
$28.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.92
|
| Rate for Payer: Medical Associates Commercial |
$26.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.93
|
| Rate for Payer: Midlands Choice Commercial |
$25.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.90
|
| Rate for Payer: United Healthcare Commercial |
$32.27
|
| Rate for Payer: United Healthcare Managed Medicare |
$21.16
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj MDV 20 mL
|
Facility
IP
|
$35.86
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702208
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.10 |
| Max. Negotiated Rate |
$32.27 |
| Rate for Payer: Aetna of IA Commercial |
$32.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.27
|
| Rate for Payer: Cash Price |
$28.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.90
|
| Rate for Payer: Medical Associates Commercial |
$26.90
|
| Rate for Payer: Midlands Choice Commercial |
$25.10
|
| Rate for Payer: United Healthcare Commercial |
$32.27
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj Sol 30 mL MDV
|
Facility
IP
|
$30.99
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43799147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.69 |
| Max. Negotiated Rate |
$27.89 |
| Rate for Payer: Aetna of IA Commercial |
$27.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.89
|
| Rate for Payer: Cash Price |
$24.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.24
|
| Rate for Payer: Medical Associates Commercial |
$23.24
|
| Rate for Payer: Midlands Choice Commercial |
$21.69
|
| Rate for Payer: United Healthcare Commercial |
$27.89
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj Sol 30 mL MDV
|
Facility
OP
|
$30.99
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43799147
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$27.89 |
| Rate for Payer: Aetna of IA Commercial |
$27.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.89
|
| Rate for Payer: Aetna of IA Medicare |
$17.66
|
| Rate for Payer: Amerigroup Medicaid |
$15.64
|
| Rate for Payer: Amerigroup Medicare |
$15.65
|
| Rate for Payer: Cash Price |
$24.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.49
|
| Rate for Payer: Medical Associates Commercial |
$23.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.50
|
| Rate for Payer: Midlands Choice Commercial |
$21.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.24
|
| Rate for Payer: United Healthcare Commercial |
$27.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.28
|
|
|
lidocaine-EPINEPHrine 2%-1:100,000 Inj MDV 20 mL
|
Facility
OP
|
$26.07
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Aetna of IA Commercial |
$23.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.46
|
| Rate for Payer: Aetna of IA Medicare |
$14.86
|
| Rate for Payer: Amerigroup Medicaid |
$13.16
|
| Rate for Payer: Amerigroup Medicare |
$13.17
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.55
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.03
|
| Rate for Payer: Medical Associates Commercial |
$19.55
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.04
|
| Rate for Payer: Midlands Choice Commercial |
$18.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.55
|
| Rate for Payer: United Healthcare Commercial |
$23.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.38
|
|
|
lidocaine-EPINEPHrine 2%-1:100,000 Inj MDV 20 mL
|
Facility
IP
|
$26.07
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Aetna of IA Commercial |
$23.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.46
|
| Rate for Payer: Cash Price |
$20.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.55
|
| Rate for Payer: Medical Associates Commercial |
$19.55
|
| Rate for Payer: Midlands Choice Commercial |
$18.25
|
| Rate for Payer: United Healthcare Commercial |
$23.46
|
|
|
lidocaine-EPINEPHrine 2%-1:200,000- PF Inj 10 mL SDV
|
Facility
IP
|
$31.41
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43744123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.99 |
| Max. Negotiated Rate |
$28.27 |
| Rate for Payer: Aetna of IA Commercial |
$28.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.27
|
| Rate for Payer: Cash Price |
$25.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.56
|
| Rate for Payer: Medical Associates Commercial |
$23.56
|
| Rate for Payer: Midlands Choice Commercial |
$21.99
|
| Rate for Payer: United Healthcare Commercial |
$28.27
|
|
|
lidocaine-EPINEPHrine 2%-1:200,000- PF Inj 10 mL SDV
|
Facility
OP
|
$31.41
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43744123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.70 |
| Max. Negotiated Rate |
$28.27 |
| Rate for Payer: Aetna of IA Commercial |
$28.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.27
|
| Rate for Payer: Aetna of IA Medicare |
$17.90
|
| Rate for Payer: Amerigroup Medicaid |
$15.85
|
| Rate for Payer: Amerigroup Medicare |
$15.86
|
| Rate for Payer: Cash Price |
$25.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.56
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.70
|
| Rate for Payer: Medical Associates Commercial |
$23.56
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.70
|
| Rate for Payer: Midlands Choice Commercial |
$21.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.56
|
| Rate for Payer: United Healthcare Commercial |
$28.27
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.53
|
|
|
lidocaine in D5W 2000 mg sol 4 mg/ml 500ml
|
Facility
OP
|
$63.36
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43798686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.67 |
| Max. Negotiated Rate |
$57.02 |
| Rate for Payer: Aetna of IA Commercial |
$57.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.02
|
| Rate for Payer: Aetna of IA Medicare |
$36.12
|
| Rate for Payer: Amerigroup Medicaid |
$31.98
|
| Rate for Payer: Amerigroup Medicare |
$32.00
|
| Rate for Payer: Cash Price |
$50.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.52
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.67
|
| Rate for Payer: Medical Associates Commercial |
$47.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.68
|
| Rate for Payer: Midlands Choice Commercial |
$44.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.52
|
| Rate for Payer: United Healthcare Commercial |
$57.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.38
|
|
|
lidocaine in D5W 2000 mg sol 4 mg/ml 500ml
|
Facility
IP
|
$63.36
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43798686
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.35 |
| Max. Negotiated Rate |
$57.02 |
| Rate for Payer: Aetna of IA Commercial |
$57.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.02
|
| Rate for Payer: Cash Price |
$50.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.52
|
| Rate for Payer: Medical Associates Commercial |
$47.52
|
| Rate for Payer: Midlands Choice Commercial |
$44.35
|
| Rate for Payer: United Healthcare Commercial |
$57.02
|
|
|
lidocaine-prilocaine Top 2.5%-2.5% kit
|
Facility
OP
|
$35.18
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43715977
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.58 |
| Max. Negotiated Rate |
$31.66 |
| Rate for Payer: Aetna of IA Commercial |
$31.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$31.66
|
| Rate for Payer: Aetna of IA Medicare |
$20.05
|
| Rate for Payer: Amerigroup Medicaid |
$17.76
|
| Rate for Payer: Amerigroup Medicare |
$17.77
|
| Rate for Payer: Cash Price |
$28.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.58
|
| Rate for Payer: Medical Associates Commercial |
$26.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.59
|
| Rate for Payer: Midlands Choice Commercial |
$24.63
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.38
|
| Rate for Payer: United Healthcare Commercial |
$31.66
|
| Rate for Payer: United Healthcare Managed Medicare |
$20.76
|
|
|
lidocaine-prilocaine Top 2.5%-2.5% kit
|
Facility
IP
|
$35.18
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43715977
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.63 |
| Max. Negotiated Rate |
$31.66 |
| Rate for Payer: Aetna of IA Commercial |
$31.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$31.66
|
| Rate for Payer: Cash Price |
$28.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.38
|
| Rate for Payer: Medical Associates Commercial |
$26.38
|
| Rate for Payer: Midlands Choice Commercial |
$24.63
|
| Rate for Payer: United Healthcare Commercial |
$31.66
|
|
|
lidocaine topical 2% Viscous Sol
|
Facility
OP
|
$8.08
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43714579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$7.27 |
| Rate for Payer: Aetna of IA Commercial |
$7.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.27
|
| Rate for Payer: Aetna of IA Medicare |
$4.61
|
| Rate for Payer: Amerigroup Medicaid |
$4.08
|
| Rate for Payer: Amerigroup Medicare |
$4.08
|
| Rate for Payer: Cash Price |
$6.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.04
|
| Rate for Payer: Medical Associates Commercial |
$6.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.04
|
| Rate for Payer: Midlands Choice Commercial |
$5.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.06
|
| Rate for Payer: United Healthcare Commercial |
$7.27
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.77
|
|
|
lidocaine topical 2% Viscous Sol
|
Facility
IP
|
$8.08
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43714579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$7.27 |
| Rate for Payer: Aetna of IA Commercial |
$7.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.27
|
| Rate for Payer: Cash Price |
$6.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.06
|
| Rate for Payer: Medical Associates Commercial |
$6.06
|
| Rate for Payer: Midlands Choice Commercial |
$5.66
|
| Rate for Payer: United Healthcare Commercial |
$7.27
|
|
