|
lidocaine 1% 10 ml MDV [VDMC]
|
Facility
|
OP
|
$28.98
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
13648301
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna of IA Commercial |
$26.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.08
|
| Rate for Payer: Aetna of IA Medicare |
$16.52
|
| Rate for Payer: Amerigroup Medicaid |
$14.63
|
| Rate for Payer: Amerigroup Medicare |
$14.63
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.74
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.48
|
| Rate for Payer: Medical Associates Commercial |
$21.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.49
|
| Rate for Payer: Midlands Choice Commercial |
$20.29
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.71
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$14.70
|
| Rate for Payer: Oscar Health of IA Commercial |
$21.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.74
|
| Rate for Payer: United Healthcare Commercial |
$26.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.10
|
|
|
lidocaine 1% 200mg/20ml MDV 20ml [VDMC]
|
Facility
|
IP
|
$25.84
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10441819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.09 |
| Max. Negotiated Rate |
$23.26 |
| Rate for Payer: Aetna of IA Commercial |
$23.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.26
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.38
|
| Rate for Payer: Medical Associates Commercial |
$19.38
|
| Rate for Payer: Midlands Choice Commercial |
$18.09
|
| Rate for Payer: United Healthcare Commercial |
$23.26
|
|
|
lidocaine 1% 200mg/20ml MDV 20ml [VDMC]
|
Facility
|
OP
|
$25.84
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10441819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$23.26 |
| Rate for Payer: Aetna of IA Commercial |
$23.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.26
|
| Rate for Payer: Aetna of IA Medicare |
$14.73
|
| Rate for Payer: Amerigroup Medicaid |
$13.04
|
| Rate for Payer: Amerigroup Medicare |
$13.05
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.91
|
| Rate for Payer: Medical Associates Commercial |
$19.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.92
|
| Rate for Payer: Midlands Choice Commercial |
$18.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.11
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$13.11
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.38
|
| Rate for Payer: United Healthcare Commercial |
$23.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.25
|
|
|
lidocaine 1% 20mg/2 mL PF SDV [VDMC]
|
Facility
|
OP
|
$23.11
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10430909
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.80
|
| Rate for Payer: Aetna of IA Medicare |
$13.17
|
| Rate for Payer: Amerigroup Medicaid |
$11.66
|
| Rate for Payer: Amerigroup Medicare |
$11.67
|
| Rate for Payer: Cash Price |
$18.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.55
|
| Rate for Payer: Medical Associates Commercial |
$17.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.56
|
| Rate for Payer: Midlands Choice Commercial |
$16.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.73
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$11.72
|
| Rate for Payer: Oscar Health of IA Commercial |
$17.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.33
|
| Rate for Payer: United Healthcare Commercial |
$20.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.63
|
|
|
lidocaine 1% 20mg/2 mL PF SDV [VDMC]
|
Facility
|
IP
|
$23.11
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10430909
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.18 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.80
|
| Rate for Payer: Cash Price |
$18.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.33
|
| Rate for Payer: Medical Associates Commercial |
$17.33
|
| Rate for Payer: Midlands Choice Commercial |
$16.18
|
| Rate for Payer: United Healthcare Commercial |
$20.80
|
|
|
lidocaine 1% 30 mL PF SDV [VDMC]
|
Facility
|
OP
|
$63.38
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10430976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna of IA Commercial |
$57.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.04
|
| Rate for Payer: Aetna of IA Medicare |
$36.13
|
| Rate for Payer: Amerigroup Medicaid |
$31.99
|
| Rate for Payer: Amerigroup Medicare |
$32.01
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.69
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.68
|
| Rate for Payer: Medical Associates Commercial |
$47.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.69
|
| Rate for Payer: Midlands Choice Commercial |
$44.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.17
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$32.15
|
| Rate for Payer: Oscar Health of IA Commercial |
$47.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.54
|
| Rate for Payer: United Healthcare Commercial |
$57.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.39
|
|
|
lidocaine 1% 30 mL PF SDV [VDMC]
|
Facility
|
IP
|
$63.38
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10430976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.37 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna of IA Commercial |
$57.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.04
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.54
|
| Rate for Payer: Medical Associates Commercial |
$47.54
|
| Rate for Payer: Midlands Choice Commercial |
$44.37
|
| Rate for Payer: United Healthcare Commercial |
$57.04
|
|
|
lidocaine 1% 5 ml PF SDV [VDMC]
|
Facility
|
OP
|
$24.33
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
13647996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.16 |
| Max. Negotiated Rate |
$21.90 |
| Rate for Payer: Aetna of IA Commercial |
$21.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.90
|
| Rate for Payer: Aetna of IA Medicare |
$13.87
|
| Rate for Payer: Amerigroup Medicaid |
$12.28
|
| Rate for Payer: Amerigroup Medicare |
$12.29
|
| Rate for Payer: Cash Price |
$19.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.16
|
| Rate for Payer: Medical Associates Commercial |
$18.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.16
|
| Rate for Payer: Midlands Choice Commercial |
$17.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.35
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.34
|
| Rate for Payer: Oscar Health of IA Commercial |
$18.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.25
|
| Rate for Payer: United Healthcare Commercial |
$21.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.35
|
|
|
lidocaine 1% 5 ml PF SDV [VDMC]
|
Facility
|
IP
|
$24.33
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
13647996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$21.90 |
| Rate for Payer: Aetna of IA Commercial |
$21.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.90
|
| Rate for Payer: Cash Price |
$19.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.25
|
| Rate for Payer: Medical Associates Commercial |
$18.25
|
| Rate for Payer: Midlands Choice Commercial |
$17.03
|
| Rate for Payer: United Healthcare Commercial |
$21.90
|
|
|
Lidocaine 1% Phenylephrine 1.5% Opht PF Syringe [VDMC]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23138084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$58.10 |
| Max. Negotiated Rate |
$74.70 |
| Rate for Payer: Aetna of IA Commercial |
$74.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$74.70
|
| Rate for Payer: Cash Price |
$66.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$62.25
|
| Rate for Payer: Medical Associates Commercial |
$62.25
|
| Rate for Payer: Midlands Choice Commercial |
$58.10
|
| Rate for Payer: United Healthcare Commercial |
$74.70
|
|
|
Lidocaine 1% Phenylephrine 1.5% Opht PF Syringe [VDMC]
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23138084
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.48 |
| Max. Negotiated Rate |
$74.70 |
| Rate for Payer: Aetna of IA Commercial |
$74.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$74.70
|
| Rate for Payer: Aetna of IA Medicare |
$47.31
|
| Rate for Payer: Amerigroup Medicaid |
$41.89
|
| Rate for Payer: Amerigroup Medicare |
$41.92
|
| Rate for Payer: Cash Price |
$66.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$62.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$41.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$41.48
|
| Rate for Payer: Medical Associates Commercial |
$62.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$41.50
|
| Rate for Payer: Midlands Choice Commercial |
$58.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$42.12
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$42.10
|
| Rate for Payer: Oscar Health of IA Commercial |
$62.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$62.25
|
| Rate for Payer: United Healthcare Commercial |
$74.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.97
|
|
|
lidocaine 2% 200mg/10 mL MDV [VDMC]
|
Facility
|
IP
|
$26.92
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
24290303
|
|
Hospital Revenue Code
|
259
|
| 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% 200mg/10 mL MDV [VDMC]
|
Facility
|
OP
|
$26.92
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
24290303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.45 |
| 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: Aetna of IA Medicare |
$15.34
|
| Rate for Payer: Amerigroup Medicaid |
$13.59
|
| Rate for Payer: Amerigroup Medicare |
$13.59
|
| Rate for Payer: Cash Price |
$21.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.45
|
| Rate for Payer: Medical Associates Commercial |
$20.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.46
|
| Rate for Payer: Midlands Choice Commercial |
$18.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.66
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$13.65
|
| Rate for Payer: Oscar Health of IA Commercial |
$20.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.19
|
| Rate for Payer: United Healthcare Commercial |
$24.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.88
|
|
|
lidocaine 2% 400mg/20 mL MDV [VDMC]
|
Facility
|
OP
|
$25.49
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10440174
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$12.93
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.12
|
| 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 2% 400mg/20 mL MDV [VDMC]
|
Facility
|
IP
|
$25.49
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10440174
|
|
Hospital Revenue Code
|
259
|
| 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 4% PF 5 ML SDV [VDMC]
|
Facility
|
IP
|
$32.51
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10431043
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$32.51
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10431043
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$16.49
|
| Rate for Payer: Oscar Health of IA Commercial |
$24.38
|
| 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 [VDMC]
|
Facility
|
IP
|
$42.19
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10433017
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$42.19
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10433017
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$21.40
|
| Rate for Payer: Oscar Health of IA Commercial |
$31.64
|
| 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 {VDMC]
|
Facility
|
IP
|
$56.93
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
21224738
|
|
Hospital Revenue Code
|
259
|
| 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 {VDMC]
|
Facility
|
OP
|
$56.93
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
21224738
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$28.87
|
| Rate for Payer: Oscar Health of IA Commercial |
$42.70
|
| 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 [VDMC]
|
Facility
|
IP
|
$26.44
|
|
|
Service Code
|
HCPCS CN204
|
| Hospital Charge Code |
12500376
|
|
Hospital Revenue Code
|
259
|
| 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 10 mL MDV [VDMC]
|
Facility
|
OP
|
$26.44
|
|
|
Service Code
|
HCPCS CN204
|
| Hospital Charge Code |
12500376
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$13.41
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.83
|
| 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 MDV 20 mL [VDMC]
|
Facility
|
IP
|
$35.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10386375
|
|
Hospital Revenue Code
|
259
|
| 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 MDV 20 mL [VDMC]
|
Facility
|
OP
|
$35.86
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10386375
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$18.19
|
| Rate for Payer: Oscar Health of IA Commercial |
$26.90
|
| 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
|
|
