|
lidocaine-EPINEPHrine 1%-1:100,000 Inj Sol 30 mL MDV [VDMC]
|
Facility
|
IP
|
$30.99
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10386442
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$30.99
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10386442
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$15.72
|
| Rate for Payer: Oscar Health of IA Commercial |
$23.24
|
| 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[VDMC]
|
Facility
|
OP
|
$26.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10386509
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$13.22
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.55
|
| 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[VDMC]
|
Facility
|
IP
|
$26.07
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10386509
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
IP
|
$31.41
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10386643
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$31.41
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10386643
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$15.93
|
| Rate for Payer: Oscar Health of IA Commercial |
$23.56
|
| 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-epinephrine/tetracaine topical 4000 mg-180 mg-500 mg/100 mL Pow [VDMC]
|
Facility
|
IP
|
$18.57
|
|
|
Service Code
|
NDC 51552-1345-01
|
| Hospital Charge Code |
10386310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$16.71 |
| Rate for Payer: Aetna of IA Commercial |
$16.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.71
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.93
|
| Rate for Payer: Medical Associates Commercial |
$13.93
|
| Rate for Payer: Midlands Choice Commercial |
$13.00
|
| Rate for Payer: United Healthcare Commercial |
$16.71
|
|
|
lidocaine-epinephrine/tetracaine topical 4000 mg-180 mg-500 mg/100 mL Pow [VDMC]
|
Facility
|
OP
|
$18.57
|
|
|
Service Code
|
NDC 51552-1345-01
|
| Hospital Charge Code |
10386310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$16.71 |
| Rate for Payer: Aetna of IA Commercial |
$16.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.71
|
| Rate for Payer: Aetna of IA Medicare |
$10.58
|
| Rate for Payer: Amerigroup Medicaid |
$9.37
|
| Rate for Payer: Amerigroup Medicare |
$9.38
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.93
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.28
|
| Rate for Payer: Medical Associates Commercial |
$13.93
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.28
|
| Rate for Payer: Midlands Choice Commercial |
$13.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.42
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$9.42
|
| Rate for Payer: Oscar Health of IA Commercial |
$13.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.93
|
| Rate for Payer: United Healthcare Commercial |
$16.71
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.96
|
|
|
lidocaine in D5W 2000 mg sol 4 mg/ml 500ml [VDMC]
|
Facility
|
OP
|
$63.36
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10432832
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$32.14
|
| Rate for Payer: Oscar Health of IA Commercial |
$47.52
|
| 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 [VDMC]
|
Facility
|
IP
|
$63.36
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
10432832
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
IP
|
$35.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10429506
|
|
Hospital Revenue Code
|
259
|
| 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-prilocaine Top 2.5%-2.5% kit [VDMC]
|
Facility
|
OP
|
$35.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10429506
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$17.84
|
| Rate for Payer: Oscar Health of IA Commercial |
$26.38
|
| 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 Top 2% Gel w/Appl 5 ML [VDMC]
|
Facility
|
IP
|
$25.66
|
|
|
Service Code
|
NDC 76329-3012-05
|
| Hospital Charge Code |
10435444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$23.09 |
| Rate for Payer: Aetna of IA Commercial |
$23.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.09
|
| Rate for Payer: Cash Price |
$20.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.24
|
| Rate for Payer: Medical Associates Commercial |
$19.24
|
| Rate for Payer: Midlands Choice Commercial |
$17.96
|
| Rate for Payer: United Healthcare Commercial |
$23.09
|
|
|
lidocaine Top 2% Gel w/Appl 5 ML [VDMC]
|
Facility
|
OP
|
$25.66
|
|
|
Service Code
|
NDC 76329-3012-05
|
| Hospital Charge Code |
10435444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.82 |
| Max. Negotiated Rate |
$23.09 |
| Rate for Payer: Aetna of IA Commercial |
$23.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.09
|
| Rate for Payer: Aetna of IA Medicare |
$14.63
|
| Rate for Payer: Amerigroup Medicaid |
$12.95
|
| Rate for Payer: Amerigroup Medicare |
$12.96
|
| Rate for Payer: Cash Price |
$20.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.83
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.82
|
| Rate for Payer: Medical Associates Commercial |
$19.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.83
|
| Rate for Payer: Midlands Choice Commercial |
$17.96
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.02
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$13.01
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare Commercial |
$23.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.14
|
|
|
lidocaine topical 2% Viscous Sol [VDMC]
|
Facility
|
IP
|
$8.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222149
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
lidocaine topical 2% Viscous Sol [VDMC]
|
Facility
|
OP
|
$8.08
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222149
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$4.10
|
| Rate for Payer: Oscar Health of IA Commercial |
$6.06
|
| 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 4% Sol 50ml[VDMC]
|
Facility
|
IP
|
$15.40
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435511
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$13.86 |
| Rate for Payer: Aetna of IA Commercial |
$13.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.86
|
| Rate for Payer: Cash Price |
$12.32
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.55
|
| Rate for Payer: Medical Associates Commercial |
$11.55
|
| Rate for Payer: Midlands Choice Commercial |
$10.78
|
| Rate for Payer: United Healthcare Commercial |
$13.86
|
|
|
lidocaine Topical 4% Sol 50ml[VDMC]
|
Facility
|
OP
|
$15.40
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435511
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$13.86 |
| Rate for Payer: Aetna of IA Commercial |
$13.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.86
|
| Rate for Payer: Aetna of IA Medicare |
$8.78
|
| Rate for Payer: Amerigroup Medicaid |
$7.77
|
| Rate for Payer: Amerigroup Medicare |
$7.78
|
| Rate for Payer: Cash Price |
$12.32
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.55
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.70
|
| Rate for Payer: Medical Associates Commercial |
$11.55
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.70
|
| Rate for Payer: Midlands Choice Commercial |
$10.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.82
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$7.81
|
| Rate for Payer: Oscar Health of IA Commercial |
$11.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.55
|
| Rate for Payer: United Healthcare Commercial |
$13.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.09
|
|
|
lidocaine Top Patch 5% film [VDMC]
|
Facility
|
OP
|
$14.21
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435576
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.10 |
| Max. Negotiated Rate |
$12.79 |
| Rate for Payer: Aetna of IA Commercial |
$12.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.79
|
| Rate for Payer: Aetna of IA Medicare |
$8.10
|
| Rate for Payer: Amerigroup Medicaid |
$7.17
|
| Rate for Payer: Amerigroup Medicare |
$7.18
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.10
|
| Rate for Payer: Medical Associates Commercial |
$10.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.10
|
| Rate for Payer: Midlands Choice Commercial |
$9.95
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.21
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$7.21
|
| Rate for Payer: Oscar Health of IA Commercial |
$10.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.66
|
| Rate for Payer: United Healthcare Commercial |
$12.79
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.38
|
|
|
lidocaine Top Patch 5% film [VDMC]
|
Facility
|
IP
|
$14.21
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435576
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$12.79 |
| Rate for Payer: Aetna of IA Commercial |
$12.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.79
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.66
|
| Rate for Payer: Medical Associates Commercial |
$10.66
|
| Rate for Payer: Midlands Choice Commercial |
$9.95
|
| Rate for Payer: United Healthcare Commercial |
$12.79
|
|
|
LIGATION OF HEMORRHOID(S)
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
CPT 46221
|
| Hospital Charge Code |
4864973
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$733.50 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
|
|
LIGATION OF HEMORRHOID(S)
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
CPT 46221
|
| Hospital Charge Code |
4864973
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$407.34 |
| Max. Negotiated Rate |
$1,451.30 |
| Rate for Payer: Aetna of IA Commercial |
$733.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$733.50
|
| Rate for Payer: Aetna of IA Medicare |
$464.55
|
| Rate for Payer: Amerigroup Medicaid |
$411.33
|
| Rate for Payer: Amerigroup Medicare |
$411.58
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Cash Price |
$652.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$611.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$407.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$407.34
|
| Rate for Payer: Medical Associates Commercial |
$611.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$407.50
|
| Rate for Payer: Midlands Choice Commercial |
$570.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$413.61
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$413.37
|
| Rate for Payer: Oscar Health of IA Commercial |
$611.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$611.25
|
| Rate for Payer: United Healthcare Commercial |
$733.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$480.85
|
| Rate for Payer: Wellmark IA HMO |
$1,319.36
|
| Rate for Payer: Wellmark IA PPO |
$1,451.30
|
|
|
Light Chains Quantitative DMCL
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
8037726
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna of IA Commercial |
$117.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.00
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$97.50
|
| Rate for Payer: Medical Associates Commercial |
$97.50
|
| Rate for Payer: Midlands Choice Commercial |
$91.00
|
| Rate for Payer: United Healthcare Commercial |
$117.00
|
|
|
Light Chains Quantitative DMCL
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
8037726
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: Aetna of IA Commercial |
$117.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.00
|
| Rate for Payer: Aetna of IA Medicare |
$74.10
|
| Rate for Payer: Amerigroup Medicaid |
$65.61
|
| Rate for Payer: Amerigroup Medicare |
$65.65
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$97.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$65.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$64.97
|
| Rate for Payer: Medical Associates Commercial |
$97.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.00
|
| Rate for Payer: Midlands Choice Commercial |
$91.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$65.98
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$65.94
|
| Rate for Payer: Oscar Health of IA Commercial |
$97.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$97.50
|
| Rate for Payer: United Healthcare Commercial |
$117.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$76.70
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
Limb Reattachment, Hip and Femur Procedures for Multiple Significant Trauma
|
Facility
|
IP
|
$47,847.92
|
|
|
Service Code
|
MS-DRG 956
|
| Hospital Charge Code |
659
|
| Min. Negotiated Rate |
$47,154.47 |
| Max. Negotiated Rate |
$47,847.92 |
| Rate for Payer: Amerigroup Medicaid |
$47,616.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$47,154.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$47,847.92
|
|
