|
lidocaine-epinephrine 1:100000-1% 500mg/50ml MDV inj {VDMC]
|
Facility
|
OP
|
$62.02
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
21224738
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.91 |
| Max. Negotiated Rate |
$55.82 |
| Rate for Payer: Aetna of IA Commercial |
$55.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.82
|
| Rate for Payer: Aetna of IA Medicare |
$35.35
|
| Rate for Payer: Amerigroup Medicaid |
$35.77
|
| Rate for Payer: Amerigroup Medicare |
$28.19
|
| Rate for Payer: Cash Price |
$49.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.42
|
| Rate for Payer: Medical Associates Commercial |
$46.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.91
|
| Rate for Payer: Midlands Choice Commercial |
$43.41
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.09
|
| Rate for Payer: United Healthcare Commercial |
$55.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.59
|
|
|
lidocaine-epinephrine 1:100000-1% 500mg/50ml MDV inj {VDMC]
|
Facility
|
IP
|
$62.02
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
21224738
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$43.41 |
| Max. Negotiated Rate |
$55.82 |
| Rate for Payer: Aetna of IA Commercial |
$55.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.82
|
| Rate for Payer: Cash Price |
$49.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.51
|
| Rate for Payer: Medical Associates Commercial |
$46.51
|
| Rate for Payer: Midlands Choice Commercial |
$43.41
|
| Rate for Payer: United Healthcare Commercial |
$55.82
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj 10 mL MDV [VDMC]
|
Facility
|
IP
|
$26.44
|
|
|
Service Code
|
HCPCS J2004
|
| 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 J2004
|
| Hospital Charge Code |
12500376
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.90 |
| 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 |
$15.25
|
| Rate for Payer: Amerigroup Medicare |
$12.02
|
| 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 |
$11.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.10
|
| Rate for Payer: Medical Associates Commercial |
$19.83
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.90
|
| Rate for Payer: Midlands Choice Commercial |
$18.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.68
|
| 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
|
OP
|
$38.07
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10386375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.13 |
| Max. Negotiated Rate |
$34.26 |
| Rate for Payer: Aetna of IA Commercial |
$34.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.26
|
| Rate for Payer: Aetna of IA Medicare |
$21.70
|
| Rate for Payer: Amerigroup Medicaid |
$21.96
|
| Rate for Payer: Amerigroup Medicare |
$17.30
|
| Rate for Payer: Cash Price |
$30.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.55
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.13
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.74
|
| Rate for Payer: Medical Associates Commercial |
$28.55
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.13
|
| Rate for Payer: Midlands Choice Commercial |
$26.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.70
|
| Rate for Payer: United Healthcare Commercial |
$34.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.46
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj MDV 20 mL [VDMC]
|
Facility
|
IP
|
$38.07
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10386375
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$34.26 |
| Rate for Payer: Aetna of IA Commercial |
$34.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.26
|
| Rate for Payer: Cash Price |
$30.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.55
|
| Rate for Payer: Medical Associates Commercial |
$28.55
|
| Rate for Payer: Midlands Choice Commercial |
$26.65
|
| Rate for Payer: United Healthcare Commercial |
$34.26
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj Sol 30 mL MDV [VDMC]
|
Facility
|
OP
|
$30.99
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10386442
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.94 |
| 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 |
$17.87
|
| Rate for Payer: Amerigroup Medicare |
$14.08
|
| 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 |
$13.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.70
|
| Rate for Payer: Medical Associates Commercial |
$23.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.94
|
| Rate for Payer: Midlands Choice Commercial |
$21.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.04
|
| Rate for Payer: United Healthcare Commercial |
$27.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.28
|
|
|
lidocaine-EPINEPHrine 1%-1:100,000 Inj Sol 30 mL MDV [VDMC]
|
Facility
|
IP
|
$30.99
|
|
|
Service Code
|
HCPCS J2004
|
| 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 2%-1:100,000 Inj MDV 20 mL[VDMC]
|
Facility
|
OP
|
$38.32
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10386509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$34.49 |
| Rate for Payer: Aetna of IA Commercial |
$34.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.49
|
| Rate for Payer: Aetna of IA Medicare |
$21.84
|
| Rate for Payer: Amerigroup Medicaid |
$22.10
|
| Rate for Payer: Amerigroup Medicare |
$17.42
|
| Rate for Payer: Cash Price |
$30.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.74
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.89
|
| Rate for Payer: Medical Associates Commercial |
$28.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.25
|
| Rate for Payer: Midlands Choice Commercial |
$26.83
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.21
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.83
|
| Rate for Payer: United Healthcare Commercial |
$34.49
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.61
|
|
|
lidocaine-EPINEPHrine 2%-1:100,000 Inj MDV 20 mL[VDMC]
|
Facility
|
IP
|
$38.32
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10386509
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.83 |
| Max. Negotiated Rate |
$34.49 |
| Rate for Payer: Aetna of IA Commercial |
$34.49
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.49
|
| Rate for Payer: Cash Price |
$30.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.74
|
| Rate for Payer: Medical Associates Commercial |
$28.74
|
| Rate for Payer: Midlands Choice Commercial |
$26.83
|
| Rate for Payer: United Healthcare Commercial |
$34.49
|
|
|
lidocaine-EPINEPHrine 2%-1:200,000- PF Inj 10 mL SDV [VDMC]
|
Facility
|
OP
|
$31.41
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10386643
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.13 |
| 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 |
$18.12
|
| Rate for Payer: Amerigroup Medicare |
$14.27
|
| 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 |
$14.13
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.94
|
| Rate for Payer: Medical Associates Commercial |
$23.56
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.13
|
| Rate for Payer: Midlands Choice Commercial |
$21.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.25
|
| Rate for Payer: United Healthcare Commercial |
$28.27
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.53
|
|
|
lidocaine-EPINEPHrine 2%-1:200,000- PF Inj 10 mL SDV [VDMC]
|
Facility
|
IP
|
$31.41
|
|
|
Service Code
|
HCPCS J2004
|
| 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 in D5W 2000 mg sol 4 mg/ml 500ml [VDMC]
|
Facility
|
OP
|
$63.36
|
|
|
Service Code
|
HCPCS J2002
|
| Hospital Charge Code |
10432832
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.51 |
| 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 |
$36.55
|
| Rate for Payer: Amerigroup Medicare |
$28.80
|
| 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 |
$28.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$36.19
|
| Rate for Payer: Medical Associates Commercial |
$47.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.51
|
| Rate for Payer: Midlands Choice Commercial |
$44.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.79
|
| 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 J2002
|
| 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 |
$31.67 |
| Rate for Payer: Aetna of IA Commercial |
$31.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$31.67
|
| Rate for Payer: Cash Price |
$28.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.39
|
| Rate for Payer: Medical Associates Commercial |
$26.39
|
| Rate for Payer: Midlands Choice Commercial |
$24.63
|
| Rate for Payer: United Healthcare Commercial |
$31.67
|
|
|
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 |
$15.83 |
| Max. Negotiated Rate |
$31.67 |
| Rate for Payer: Aetna of IA Commercial |
$31.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$31.67
|
| Rate for Payer: Aetna of IA Medicare |
$20.05
|
| Rate for Payer: Amerigroup Medicaid |
$20.29
|
| Rate for Payer: Amerigroup Medicare |
$15.99
|
| Rate for Payer: Cash Price |
$28.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.83
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.10
|
| Rate for Payer: Medical Associates Commercial |
$26.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.83
|
| Rate for Payer: Midlands Choice Commercial |
$24.63
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.21
|
| Rate for Payer: United Healthcare Commercial |
$31.67
|
| Rate for Payer: United Healthcare Managed Medicare |
$20.76
|
|
|
lidocaine Top 2% Gel w/Appl 5 ML [VDMC]
|
Facility
|
OP
|
$28.79
|
|
|
Service Code
|
NDC 76329-3012-05
|
| Hospital Charge Code |
10435444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$25.91 |
| Rate for Payer: Aetna of IA Commercial |
$25.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.91
|
| Rate for Payer: Aetna of IA Medicare |
$16.41
|
| Rate for Payer: Amerigroup Medicaid |
$16.61
|
| Rate for Payer: Amerigroup Medicare |
$13.09
|
| Rate for Payer: Cash Price |
$23.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.59
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.45
|
| Rate for Payer: Medical Associates Commercial |
$21.59
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.96
|
| Rate for Payer: Midlands Choice Commercial |
$20.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.90
|
| Rate for Payer: United Healthcare Commercial |
$25.91
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.99
|
|
|
lidocaine Top 2% Gel w/Appl 5 ML [VDMC]
|
Facility
|
IP
|
$28.79
|
|
|
Service Code
|
NDC 76329-3012-05
|
| Hospital Charge Code |
10435444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.15 |
| Max. Negotiated Rate |
$25.91 |
| Rate for Payer: Aetna of IA Commercial |
$25.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.91
|
| Rate for Payer: Cash Price |
$23.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.59
|
| Rate for Payer: Medical Associates Commercial |
$21.59
|
| Rate for Payer: Midlands Choice Commercial |
$20.15
|
| Rate for Payer: United Healthcare Commercial |
$25.91
|
|
|
lidocaine topical 2% Viscous Sol [VDMC]
|
Facility
|
OP
|
$22.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222149
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$20.13 |
| Rate for Payer: Aetna of IA Commercial |
$20.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.13
|
| Rate for Payer: Aetna of IA Medicare |
$12.75
|
| Rate for Payer: Amerigroup Medicaid |
$12.90
|
| Rate for Payer: Amerigroup Medicare |
$10.17
|
| Rate for Payer: Cash Price |
$17.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.77
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.78
|
| Rate for Payer: Medical Associates Commercial |
$16.77
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.06
|
| Rate for Payer: Midlands Choice Commercial |
$15.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.57
|
| Rate for Payer: United Healthcare Commercial |
$20.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.20
|
|
|
lidocaine topical 2% Viscous Sol [VDMC]
|
Facility
|
IP
|
$22.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222149
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.66 |
| Max. Negotiated Rate |
$20.13 |
| Rate for Payer: Aetna of IA Commercial |
$20.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.13
|
| Rate for Payer: Cash Price |
$17.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.77
|
| Rate for Payer: Medical Associates Commercial |
$16.77
|
| Rate for Payer: Midlands Choice Commercial |
$15.66
|
| Rate for Payer: United Healthcare Commercial |
$20.13
|
|
|
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 |
$6.93 |
| 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 |
$8.88
|
| Rate for Payer: Amerigroup Medicare |
$7.00
|
| 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 |
$6.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.79
|
| Rate for Payer: Medical Associates Commercial |
$11.55
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.93
|
| Rate for Payer: Midlands Choice Commercial |
$10.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.97
|
| Rate for Payer: United Healthcare Commercial |
$13.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.08
|
|
|
lidocaine Top Patch 5% film [VDMC]
|
Facility
|
OP
|
$15.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435576
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$13.76 |
| Rate for Payer: Aetna of IA Commercial |
$13.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.76
|
| Rate for Payer: Aetna of IA Medicare |
$8.72
|
| Rate for Payer: Amerigroup Medicaid |
$8.82
|
| Rate for Payer: Amerigroup Medicare |
$6.95
|
| Rate for Payer: Cash Price |
$12.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.47
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.74
|
| Rate for Payer: Medical Associates Commercial |
$11.47
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.88
|
| Rate for Payer: Midlands Choice Commercial |
$10.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.91
|
| Rate for Payer: United Healthcare Commercial |
$13.76
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.02
|
|
|
lidocaine Top Patch 5% film [VDMC]
|
Facility
|
IP
|
$15.29
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435576
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$13.76 |
| Rate for Payer: Aetna of IA Commercial |
$13.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.76
|
| Rate for Payer: Cash Price |
$12.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.47
|
| Rate for Payer: Medical Associates Commercial |
$11.47
|
| Rate for Payer: Midlands Choice Commercial |
$10.71
|
| Rate for Payer: United Healthcare Commercial |
$13.76
|
|
|
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
|
|
