|
lidocaine 1% 30 mL PF SDV [VDMC]
|
Facility
|
IP
|
$32.05
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10430976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.43 |
| Max. Negotiated Rate |
$28.84 |
| Rate for Payer: Aetna of IA Commercial |
$28.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.84
|
| Rate for Payer: Cash Price |
$25.64
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.04
|
| Rate for Payer: Medical Associates Commercial |
$24.04
|
| Rate for Payer: Midlands Choice Commercial |
$22.43
|
| Rate for Payer: United Healthcare Commercial |
$28.84
|
|
|
lidocaine 1% 30 mL PF SDV [VDMC]
|
Facility
|
OP
|
$32.05
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10430976
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$28.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.84
|
| Rate for Payer: Aetna of IA Medicare |
$18.27
|
| Rate for Payer: Amerigroup Medicaid |
$18.49
|
| Rate for Payer: Amerigroup Medicare |
$14.57
|
| Rate for Payer: Cash Price |
$25.64
|
| Rate for Payer: Cash Price |
$25.64
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.04
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.31
|
| Rate for Payer: Medical Associates Commercial |
$24.04
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.42
|
| Rate for Payer: Midlands Choice Commercial |
$22.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.58
|
| Rate for Payer: United Healthcare Commercial |
$28.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.91
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 1% 5 ml PF SDV [VDMC]
|
Facility
|
IP
|
$23.83
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
13647996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.68 |
| Max. Negotiated Rate |
$21.44 |
| Rate for Payer: Aetna of IA Commercial |
$21.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.44
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.87
|
| Rate for Payer: Medical Associates Commercial |
$17.87
|
| Rate for Payer: Midlands Choice Commercial |
$16.68
|
| Rate for Payer: United Healthcare Commercial |
$21.44
|
|
|
lidocaine 1% 5 ml PF SDV [VDMC]
|
Facility
|
OP
|
$23.83
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
13647996
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.72 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$21.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.44
|
| Rate for Payer: Aetna of IA Medicare |
$13.58
|
| Rate for Payer: Amerigroup Medicaid |
$13.74
|
| Rate for Payer: Amerigroup Medicare |
$10.83
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.87
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.61
|
| Rate for Payer: Medical Associates Commercial |
$17.87
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.72
|
| Rate for Payer: Midlands Choice Commercial |
$16.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.33
|
| Rate for Payer: United Healthcare Commercial |
$21.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.06
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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 |
$37.35 |
| 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 |
$47.87
|
| Rate for Payer: Amerigroup Medicare |
$37.72
|
| 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 |
$37.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$47.41
|
| Rate for Payer: Medical Associates Commercial |
$62.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$37.35
|
| Rate for Payer: Midlands Choice Commercial |
$58.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$48.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.95
|
| 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
|
OP
|
$23.57
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
24290303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$21.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.21
|
| Rate for Payer: Aetna of IA Medicare |
$13.43
|
| Rate for Payer: Amerigroup Medicaid |
$13.59
|
| Rate for Payer: Amerigroup Medicare |
$10.71
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.46
|
| Rate for Payer: Medical Associates Commercial |
$17.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.61
|
| Rate for Payer: Midlands Choice Commercial |
$16.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.20
|
| Rate for Payer: United Healthcare Commercial |
$21.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.91
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 2% 200mg/10 mL MDV [VDMC]
|
Facility
|
IP
|
$23.57
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
24290303
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$21.21 |
| Rate for Payer: Aetna of IA Commercial |
$21.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.21
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.68
|
| Rate for Payer: Medical Associates Commercial |
$17.68
|
| Rate for Payer: Midlands Choice Commercial |
$16.50
|
| Rate for Payer: United Healthcare Commercial |
$21.21
|
|
|
lidocaine 2% 400mg/20 mL MDV [VDMC]
|
Facility
|
OP
|
$25.49
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10440174
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$221.80 |
| 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 |
$14.70
|
| Rate for Payer: Amerigroup Medicare |
$11.59
|
| Rate for Payer: Cash Price |
$20.39
|
| 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 |
$11.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.56
|
| Rate for Payer: Medical Associates Commercial |
$19.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.47
|
| Rate for Payer: Midlands Choice Commercial |
$17.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.19
|
| Rate for Payer: United Healthcare Commercial |
$22.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.04
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 2% 400mg/20 mL MDV [VDMC]
|
Facility
|
IP
|
$25.49
|
|
|
Service Code
|
HCPCS J2003
|
| 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 2% 5 mL PF SDV [VDMC]
|
Facility
|
IP
|
$23.31
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
29084093
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$20.98 |
| Rate for Payer: Aetna of IA Commercial |
$20.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.98
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.48
|
| Rate for Payer: Medical Associates Commercial |
$17.48
|
| Rate for Payer: Midlands Choice Commercial |
$16.32
|
| Rate for Payer: United Healthcare Commercial |
$20.98
|
|
|
lidocaine 2% 5 mL PF SDV [VDMC]
|
Facility
|
OP
|
$23.31
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
29084093
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.98
|
| Rate for Payer: Aetna of IA Medicare |
$13.29
|
| Rate for Payer: Amerigroup Medicaid |
$13.45
|
| Rate for Payer: Amerigroup Medicare |
$10.60
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.32
|
| Rate for Payer: Medical Associates Commercial |
$17.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.49
|
| Rate for Payer: Midlands Choice Commercial |
$16.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.06
|
| Rate for Payer: United Healthcare Commercial |
$20.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.75
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 4% PF 5 ML SDV [VDMC]
|
Facility
|
OP
|
$28.41
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10431043
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.79 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$25.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.57
|
| Rate for Payer: Aetna of IA Medicare |
$16.19
|
| Rate for Payer: Amerigroup Medicaid |
$16.39
|
| Rate for Payer: Amerigroup Medicare |
$12.91
|
| Rate for Payer: Cash Price |
$22.73
|
| Rate for Payer: Cash Price |
$22.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.31
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.79
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.23
|
| Rate for Payer: Medical Associates Commercial |
$21.31
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.79
|
| Rate for Payer: Midlands Choice Commercial |
$19.89
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.70
|
| Rate for Payer: United Healthcare Commercial |
$25.57
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.76
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
lidocaine 4% PF 5 ML SDV [VDMC]
|
Facility
|
IP
|
$28.41
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
10431043
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.89 |
| Max. Negotiated Rate |
$25.57 |
| Rate for Payer: Aetna of IA Commercial |
$25.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.57
|
| Rate for Payer: Cash Price |
$22.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.31
|
| Rate for Payer: Medical Associates Commercial |
$21.31
|
| Rate for Payer: Midlands Choice Commercial |
$19.89
|
| Rate for Payer: United Healthcare Commercial |
$25.57
|
|
|
lidocaine emergency syringe 100mg/5ml [VDMC]
|
Facility
|
IP
|
$42.19
|
|
|
Service Code
|
HCPCS J2003
|
| 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 J2003
|
| Hospital Charge Code |
10433017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$221.80 |
| 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 |
$24.33
|
| Rate for Payer: Amerigroup Medicare |
$19.17
|
| Rate for Payer: Cash Price |
$33.75
|
| 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 |
$18.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.10
|
| Rate for Payer: Medical Associates Commercial |
$31.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.98
|
| Rate for Payer: Midlands Choice Commercial |
$29.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.83
|
| Rate for Payer: United Healthcare Commercial |
$37.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.89
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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 |
$221.80 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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
|
OP
|
$26.44
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
12500376
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$221.80 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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 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 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 |
$221.80 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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 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 |
$221.80 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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 |
$221.80 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
