|
levonorgestrel 52 mg Dev 5 yrs [VDMC]
|
Facility
|
IP
|
$2,274.76
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
12564524
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,592.33 |
| Max. Negotiated Rate |
$2,047.28 |
| Rate for Payer: Aetna of IA Commercial |
$2,047.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,047.28
|
| Rate for Payer: Cash Price |
$1,819.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,706.07
|
| Rate for Payer: Medical Associates Commercial |
$1,706.07
|
| Rate for Payer: Midlands Choice Commercial |
$1,592.33
|
| Rate for Payer: United Healthcare Commercial |
$2,047.28
|
|
|
levothyroxine 100 mcg (0.1 mg) SDV Pow [VDMC]
|
Facility
|
IP
|
$266.52
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
10399995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$186.56 |
| Max. Negotiated Rate |
$239.87 |
| Rate for Payer: Aetna of IA Commercial |
$239.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$239.87
|
| Rate for Payer: Cash Price |
$213.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$199.89
|
| Rate for Payer: Medical Associates Commercial |
$199.89
|
| Rate for Payer: Midlands Choice Commercial |
$186.56
|
| Rate for Payer: United Healthcare Commercial |
$239.87
|
|
|
levothyroxine 100 mcg (0.1 mg) SDV Pow [VDMC]
|
Facility
|
OP
|
$266.52
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
10399995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$119.93 |
| Max. Negotiated Rate |
$239.87 |
| Rate for Payer: Aetna of IA Commercial |
$239.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$239.87
|
| Rate for Payer: Aetna of IA Medicare |
$151.92
|
| Rate for Payer: Amerigroup Medicaid |
$153.73
|
| Rate for Payer: Amerigroup Medicare |
$121.13
|
| Rate for Payer: Cash Price |
$213.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$199.89
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$119.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$152.24
|
| Rate for Payer: Medical Associates Commercial |
$199.89
|
| Rate for Payer: Medical Associates Managed Medicare |
$119.93
|
| Rate for Payer: Midlands Choice Commercial |
$186.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$154.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$137.92
|
| Rate for Payer: United Healthcare Commercial |
$239.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$157.25
|
|
|
levothyroxine 100 mcg (0.1 mg) Tab [VDMC]
|
Facility
|
IP
|
$2.86
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400058
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.57 |
| Rate for Payer: Aetna of IA Commercial |
$2.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.57
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.14
|
| Rate for Payer: Medical Associates Commercial |
$2.14
|
| Rate for Payer: Midlands Choice Commercial |
$2.00
|
| Rate for Payer: United Healthcare Commercial |
$2.57
|
|
|
levothyroxine 100 mcg (0.1 mg) Tab [VDMC]
|
Facility
|
OP
|
$2.86
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400058
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.57 |
| Rate for Payer: Aetna of IA Commercial |
$2.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.57
|
| Rate for Payer: Aetna of IA Medicare |
$1.63
|
| Rate for Payer: Amerigroup Medicaid |
$1.65
|
| Rate for Payer: Amerigroup Medicare |
$1.30
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.29
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.63
|
| Rate for Payer: Medical Associates Commercial |
$2.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.29
|
| Rate for Payer: Midlands Choice Commercial |
$2.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$2.57
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.68
|
|
|
levothyroxine 112 mcg (0.112 mg) Tab [VDMC]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of IA Commercial |
$1.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.09
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.91
|
| Rate for Payer: Medical Associates Commercial |
$0.91
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
|
|
levothyroxine 112 mcg (0.112 mg) Tab [VDMC]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400127
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of IA Commercial |
$1.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.09
|
| Rate for Payer: Aetna of IA Medicare |
$0.69
|
| Rate for Payer: Amerigroup Medicaid |
$0.70
|
| Rate for Payer: Amerigroup Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.91
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.69
|
| Rate for Payer: Medical Associates Commercial |
$0.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.55
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.72
|
|
|
levothyroxine 125 mcg (0.125 mg) Tab [VDMC]
|
Facility
|
OP
|
$2.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna of IA Commercial |
$2.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.29
|
| Rate for Payer: Aetna of IA Medicare |
$1.45
|
| Rate for Payer: Amerigroup Medicaid |
$1.47
|
| Rate for Payer: Amerigroup Medicare |
$1.16
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.91
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.46
|
| Rate for Payer: Medical Associates Commercial |
$1.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.15
|
| Rate for Payer: Midlands Choice Commercial |
$1.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.32
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.50
|
|
|
levothyroxine 125 mcg (0.125 mg) Tab [VDMC]
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna of IA Commercial |
$2.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.29
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.91
|
| Rate for Payer: Medical Associates Commercial |
$1.91
|
| Rate for Payer: Midlands Choice Commercial |
$1.78
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
|
|
levothyroxine 25 mcg (0.025 mg) Tab [VDMC]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400422
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Midlands Choice Commercial |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
|
|
levothyroxine 25 mcg (0.025 mg) Tab [VDMC]
|
Facility
|
OP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400422
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Aetna of IA Medicare |
$1.28
|
| Rate for Payer: Amerigroup Medicaid |
$1.30
|
| Rate for Payer: Amerigroup Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.28
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.01
|
| Rate for Payer: Midlands Choice Commercial |
$1.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
|
levothyroxine 50 mcg (0.05 mg) Tab [VDMC]
|
Facility
|
IP
|
$2.85
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
25354515
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna of IA Commercial |
$2.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.14
|
| Rate for Payer: Medical Associates Commercial |
$2.14
|
| Rate for Payer: Midlands Choice Commercial |
$1.99
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
|
|
levothyroxine 50 mcg (0.05 mg) Tab [VDMC]
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
25354515
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna of IA Commercial |
$2.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.56
|
| Rate for Payer: Aetna of IA Medicare |
$1.62
|
| Rate for Payer: Amerigroup Medicaid |
$1.64
|
| Rate for Payer: Amerigroup Medicare |
$1.29
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.63
|
| Rate for Payer: Medical Associates Commercial |
$2.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.28
|
| Rate for Payer: Midlands Choice Commercial |
$1.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.47
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.68
|
|
|
levothyroxine 75 mcg (0.075 mg) Tab [VDMC]
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna of IA Commercial |
$2.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.06
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.71
|
| Rate for Payer: Medical Associates Commercial |
$1.71
|
| Rate for Payer: Midlands Choice Commercial |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$2.06
|
|
|
levothyroxine 75 mcg (0.075 mg) Tab [VDMC]
|
Facility
|
OP
|
$2.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna of IA Commercial |
$2.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.06
|
| Rate for Payer: Aetna of IA Medicare |
$1.30
|
| Rate for Payer: Amerigroup Medicaid |
$1.32
|
| Rate for Payer: Amerigroup Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.03
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.31
|
| Rate for Payer: Medical Associates Commercial |
$1.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.03
|
| Rate for Payer: Midlands Choice Commercial |
$1.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$2.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.35
|
|
|
levothyroxine 88 mcg (0.088 mg) Tab [VDMC]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of IA Commercial |
$1.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.26
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.05
|
| Rate for Payer: Medical Associates Commercial |
$1.05
|
| Rate for Payer: Midlands Choice Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
|
|
levothyroxine 88 mcg (0.088 mg) Tab [VDMC]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10400603
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of IA Commercial |
$1.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.26
|
| Rate for Payer: Aetna of IA Medicare |
$0.80
|
| Rate for Payer: Amerigroup Medicaid |
$0.81
|
| Rate for Payer: Amerigroup Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.05
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.80
|
| Rate for Payer: Medical Associates Commercial |
$1.05
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.63
|
| Rate for Payer: Midlands Choice Commercial |
$0.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.72
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.83
|
|
|
lidocaine 0.5% 50 ml PF SDV [VDMC]
|
Facility
|
OP
|
$27.93
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10430842
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.57 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$25.14
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.14
|
| Rate for Payer: Aetna of IA Medicare |
$15.92
|
| Rate for Payer: Amerigroup Medicaid |
$16.11
|
| Rate for Payer: Amerigroup Medicare |
$12.70
|
| Rate for Payer: Cash Price |
$22.35
|
| Rate for Payer: Cash Price |
$22.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.95
|
| Rate for Payer: Medical Associates Commercial |
$20.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.57
|
| Rate for Payer: Midlands Choice Commercial |
$19.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.45
|
| Rate for Payer: United Healthcare Commercial |
$25.14
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.48
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 0.5% 50 ml PF SDV [VDMC]
|
Facility
|
IP
|
$27.93
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10430842
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$25.14 |
| Rate for Payer: Aetna of IA Commercial |
$25.14
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.14
|
| Rate for Payer: Cash Price |
$22.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.95
|
| Rate for Payer: Medical Associates Commercial |
$20.95
|
| Rate for Payer: Midlands Choice Commercial |
$19.55
|
| Rate for Payer: United Healthcare Commercial |
$25.14
|
|
|
lidocaine 1% 10 ml MDV [VDMC]
|
Facility
|
IP
|
$29.79
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
13648301
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.85 |
| Max. Negotiated Rate |
$26.81 |
| Rate for Payer: Aetna of IA Commercial |
$26.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.81
|
| Rate for Payer: Cash Price |
$23.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.34
|
| Rate for Payer: Medical Associates Commercial |
$22.34
|
| Rate for Payer: Midlands Choice Commercial |
$20.85
|
| Rate for Payer: United Healthcare Commercial |
$26.81
|
|
|
lidocaine 1% 10 ml MDV [VDMC]
|
Facility
|
OP
|
$29.79
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
13648301
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.40 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$26.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.81
|
| Rate for Payer: Aetna of IA Medicare |
$16.98
|
| Rate for Payer: Amerigroup Medicaid |
$17.18
|
| Rate for Payer: Amerigroup Medicare |
$13.54
|
| Rate for Payer: Cash Price |
$23.83
|
| Rate for Payer: Cash Price |
$23.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.01
|
| Rate for Payer: Medical Associates Commercial |
$22.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.40
|
| Rate for Payer: Midlands Choice Commercial |
$20.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.41
|
| Rate for Payer: United Healthcare Commercial |
$26.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.57
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 1% 200mg/20ml MDV 20ml [VDMC]
|
Facility
|
OP
|
$25.84
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10441819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.63 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$23.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.25
|
| Rate for Payer: Aetna of IA Medicare |
$14.73
|
| Rate for Payer: Amerigroup Medicaid |
$14.90
|
| Rate for Payer: Amerigroup Medicare |
$11.74
|
| Rate for Payer: Cash Price |
$20.67
|
| 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 |
$11.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.76
|
| Rate for Payer: Medical Associates Commercial |
$19.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.63
|
| Rate for Payer: Midlands Choice Commercial |
$18.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.37
|
| Rate for Payer: United Healthcare Commercial |
$23.25
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.24
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 1% 200mg/20ml MDV 20ml [VDMC]
|
Facility
|
IP
|
$25.84
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10441819
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.08 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna of IA Commercial |
$23.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.25
|
| 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 |
$18.08
|
| Rate for Payer: United Healthcare Commercial |
$23.25
|
|
|
lidocaine 1% 20mg/2 mL PF SDV [VDMC]
|
Facility
|
OP
|
$28.68
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10430909
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$25.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.81
|
| Rate for Payer: Aetna of IA Medicare |
$16.35
|
| Rate for Payer: Amerigroup Medicaid |
$16.54
|
| Rate for Payer: Amerigroup Medicare |
$13.04
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.38
|
| Rate for Payer: Medical Associates Commercial |
$21.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.91
|
| Rate for Payer: Midlands Choice Commercial |
$20.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.84
|
| Rate for Payer: United Healthcare Commercial |
$25.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.92
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 1% 20mg/2 mL PF SDV [VDMC]
|
Facility
|
IP
|
$28.68
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10430909
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.08 |
| Max. Negotiated Rate |
$25.81 |
| Rate for Payer: Aetna of IA Commercial |
$25.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.81
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.51
|
| Rate for Payer: Medical Associates Commercial |
$21.51
|
| Rate for Payer: Midlands Choice Commercial |
$20.08
|
| Rate for Payer: United Healthcare Commercial |
$25.81
|
|
