|
NON-LOCKING SCREW 2.7MMx16MM
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8967554
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$151.20 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna of IA Commercial |
$194.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$194.40
|
| Rate for Payer: Cash Price |
$172.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$162.00
|
| Rate for Payer: Medical Associates Commercial |
$162.00
|
| Rate for Payer: Midlands Choice Commercial |
$151.20
|
| Rate for Payer: United Healthcare Commercial |
$194.40
|
|
|
NON-LOCKING SCREW 3.5MMX12MM
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8793251
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$89.10 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Aetna of IA Commercial |
$178.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.20
|
| Rate for Payer: Aetna of IA Medicare |
$112.86
|
| Rate for Payer: Amerigroup Medicaid |
$114.21
|
| Rate for Payer: Amerigroup Medicare |
$89.99
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$148.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$89.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$113.10
|
| Rate for Payer: Medical Associates Commercial |
$148.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$89.10
|
| Rate for Payer: Midlands Choice Commercial |
$138.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$114.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$102.47
|
| Rate for Payer: United Healthcare Commercial |
$178.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$116.82
|
|
|
NON-LOCKING SCREW 3.5MMX12MM
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8793251
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Aetna of IA Commercial |
$178.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.20
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$148.50
|
| Rate for Payer: Medical Associates Commercial |
$148.50
|
| Rate for Payer: Midlands Choice Commercial |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$178.20
|
|
|
NON-LOCKING SCREW 4.0MMX16MM
|
Facility
|
IP
|
$333.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8986279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$233.10 |
| Max. Negotiated Rate |
$299.70 |
| Rate for Payer: Aetna of IA Commercial |
$299.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$299.70
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$249.75
|
| Rate for Payer: Medical Associates Commercial |
$249.75
|
| Rate for Payer: Midlands Choice Commercial |
$233.10
|
| Rate for Payer: United Healthcare Commercial |
$299.70
|
|
|
NON-LOCKING SCREW 4.0MMX16MM
|
Facility
|
OP
|
$333.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8986279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$149.85 |
| Max. Negotiated Rate |
$299.70 |
| Rate for Payer: Aetna of IA Commercial |
$299.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$299.70
|
| Rate for Payer: Aetna of IA Medicare |
$189.81
|
| Rate for Payer: Amerigroup Medicaid |
$192.07
|
| Rate for Payer: Amerigroup Medicare |
$151.35
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$249.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$149.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$190.21
|
| Rate for Payer: Medical Associates Commercial |
$249.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$149.85
|
| Rate for Payer: Midlands Choice Commercial |
$233.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$193.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$172.33
|
| Rate for Payer: United Healthcare Commercial |
$299.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$196.47
|
|
|
NON-LOCKING SCREW 4.0MMX50MM
|
Facility
|
OP
|
$333.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8986281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$149.85 |
| Max. Negotiated Rate |
$299.70 |
| Rate for Payer: Aetna of IA Commercial |
$299.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$299.70
|
| Rate for Payer: Aetna of IA Medicare |
$189.81
|
| Rate for Payer: Amerigroup Medicaid |
$192.07
|
| Rate for Payer: Amerigroup Medicare |
$151.35
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$249.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$149.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$190.21
|
| Rate for Payer: Medical Associates Commercial |
$249.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$149.85
|
| Rate for Payer: Midlands Choice Commercial |
$233.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$193.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$172.33
|
| Rate for Payer: United Healthcare Commercial |
$299.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$196.47
|
|
|
NON-LOCKING SCREW 4.0MMX50MM
|
Facility
|
IP
|
$333.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8986281
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$233.10 |
| Max. Negotiated Rate |
$299.70 |
| Rate for Payer: Aetna of IA Commercial |
$299.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$299.70
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$249.75
|
| Rate for Payer: Medical Associates Commercial |
$249.75
|
| Rate for Payer: Midlands Choice Commercial |
$233.10
|
| Rate for Payer: United Healthcare Commercial |
$299.70
|
|
|
NON-STERILE SNIPER STAPLE IMPLANTS 20X20X20
|
Facility
|
OP
|
$1,629.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8837859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$733.05 |
| Max. Negotiated Rate |
$1,466.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,466.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,466.10
|
| Rate for Payer: Aetna of IA Medicare |
$928.53
|
| Rate for Payer: Amerigroup Medicaid |
$939.61
|
| Rate for Payer: Amerigroup Medicare |
$740.38
|
| Rate for Payer: Cash Price |
$1,303.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,221.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$733.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$930.48
|
| Rate for Payer: Medical Associates Commercial |
$1,221.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$733.05
|
| Rate for Payer: Midlands Choice Commercial |
$1,140.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$944.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$843.01
|
| Rate for Payer: United Healthcare Commercial |
$1,466.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$961.11
|
|
|
NON-STERILE SNIPER STAPLE IMPLANTS 20X20X20
|
Facility
|
IP
|
$1,629.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8837859
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.30 |
| Max. Negotiated Rate |
$1,466.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,466.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,466.10
|
| Rate for Payer: Cash Price |
$1,303.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,221.75
|
| Rate for Payer: Medical Associates Commercial |
$1,221.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,140.30
|
| Rate for Payer: United Healthcare Commercial |
$1,466.10
|
|
|
NON-STERILE SNIPER STAPLE IMPLANTS 8X8X8
|
Facility
|
OP
|
$1,368.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8830151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$615.60 |
| Max. Negotiated Rate |
$1,231.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,231.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,231.20
|
| Rate for Payer: Aetna of IA Medicare |
$779.76
|
| Rate for Payer: Amerigroup Medicaid |
$789.06
|
| Rate for Payer: Amerigroup Medicare |
$621.76
|
| Rate for Payer: Cash Price |
$1,094.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,026.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$615.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$781.40
|
| Rate for Payer: Medical Associates Commercial |
$1,026.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$615.60
|
| Rate for Payer: Midlands Choice Commercial |
$957.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$792.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$707.94
|
| Rate for Payer: United Healthcare Commercial |
$1,231.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$807.12
|
|
|
NON-STERILE SNIPER STAPLE IMPLANTS 8X8X8
|
Facility
|
IP
|
$1,368.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8830151
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$957.60 |
| Max. Negotiated Rate |
$1,231.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,231.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,231.20
|
| Rate for Payer: Cash Price |
$1,094.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,026.00
|
| Rate for Payer: Medical Associates Commercial |
$1,026.00
|
| Rate for Payer: Midlands Choice Commercial |
$957.60
|
| Rate for Payer: United Healthcare Commercial |
$1,231.20
|
|
|
NON-STRES TEST (COB)
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
4096783
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$322.70 |
| Max. Negotiated Rate |
$414.90 |
| Rate for Payer: Aetna of IA Commercial |
$414.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$414.90
|
| Rate for Payer: Cash Price |
$368.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$345.75
|
| Rate for Payer: Medical Associates Commercial |
$345.75
|
| Rate for Payer: Midlands Choice Commercial |
$322.70
|
| Rate for Payer: United Healthcare Commercial |
$414.90
|
|
|
NON-STRES TEST (COB)
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
4126788
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$322.70 |
| Max. Negotiated Rate |
$414.90 |
| Rate for Payer: Aetna of IA Commercial |
$414.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$414.90
|
| Rate for Payer: Cash Price |
$368.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$345.75
|
| Rate for Payer: Medical Associates Commercial |
$345.75
|
| Rate for Payer: Midlands Choice Commercial |
$322.70
|
| Rate for Payer: United Healthcare Commercial |
$414.90
|
|
|
NON-STRES TEST (COB)
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
4096783
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$207.45 |
| Max. Negotiated Rate |
$414.90 |
| Rate for Payer: Aetna of IA Commercial |
$414.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$414.90
|
| Rate for Payer: Aetna of IA Medicare |
$262.77
|
| Rate for Payer: Amerigroup Medicaid |
$265.90
|
| Rate for Payer: Amerigroup Medicare |
$209.52
|
| Rate for Payer: Cash Price |
$368.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$345.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$207.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$263.32
|
| Rate for Payer: Medical Associates Commercial |
$345.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$207.45
|
| Rate for Payer: Midlands Choice Commercial |
$322.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$267.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$238.57
|
| Rate for Payer: United Healthcare Commercial |
$414.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$271.99
|
|
|
NON-STRES TEST (COB)
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
4126788
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$207.45 |
| Max. Negotiated Rate |
$414.90 |
| Rate for Payer: Aetna of IA Commercial |
$414.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$414.90
|
| Rate for Payer: Aetna of IA Medicare |
$262.77
|
| Rate for Payer: Amerigroup Medicaid |
$265.90
|
| Rate for Payer: Amerigroup Medicare |
$209.52
|
| Rate for Payer: Cash Price |
$368.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$345.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$207.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$263.32
|
| Rate for Payer: Medical Associates Commercial |
$345.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$207.45
|
| Rate for Payer: Midlands Choice Commercial |
$322.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$267.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$238.57
|
| Rate for Payer: United Healthcare Commercial |
$414.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$271.99
|
|
|
norEPINEPHrine 1 mg/mL 4 ml SDV IV Sol [VDMC]
|
Facility
|
IP
|
$32.14
|
|
|
Service Code
|
NDC 43066-0997-10
|
| Hospital Charge Code |
10409340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$28.93 |
| Rate for Payer: Aetna of IA Commercial |
$28.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.93
|
| Rate for Payer: Cash Price |
$25.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.11
|
| Rate for Payer: Medical Associates Commercial |
$24.11
|
| Rate for Payer: Midlands Choice Commercial |
$22.50
|
| Rate for Payer: United Healthcare Commercial |
$28.93
|
|
|
norEPINEPHrine 1 mg/mL 4 ml SDV IV Sol [VDMC]
|
Facility
|
OP
|
$32.14
|
|
|
Service Code
|
NDC 43066-0997-10
|
| Hospital Charge Code |
10409340
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.46 |
| Max. Negotiated Rate |
$28.93 |
| Rate for Payer: Aetna of IA Commercial |
$28.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.93
|
| Rate for Payer: Aetna of IA Medicare |
$18.32
|
| Rate for Payer: Amerigroup Medicaid |
$18.54
|
| Rate for Payer: Amerigroup Medicare |
$14.61
|
| Rate for Payer: Cash Price |
$25.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.11
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.36
|
| Rate for Payer: Medical Associates Commercial |
$24.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.46
|
| Rate for Payer: Midlands Choice Commercial |
$22.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.63
|
| Rate for Payer: United Healthcare Commercial |
$28.93
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.96
|
|
|
NOREPINEPHRINE 4 MG/250 ML-D5W [VDMC]
|
Facility
|
OP
|
$123.58
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
23229588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.61 |
| Max. Negotiated Rate |
$111.22 |
| Rate for Payer: Aetna of IA Commercial |
$111.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$111.22
|
| Rate for Payer: Aetna of IA Medicare |
$70.44
|
| Rate for Payer: Amerigroup Medicaid |
$71.28
|
| Rate for Payer: Amerigroup Medicare |
$56.17
|
| Rate for Payer: Cash Price |
$98.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$92.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$70.59
|
| Rate for Payer: Medical Associates Commercial |
$92.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.61
|
| Rate for Payer: Midlands Choice Commercial |
$86.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$71.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.95
|
| Rate for Payer: United Healthcare Commercial |
$111.22
|
| Rate for Payer: United Healthcare Managed Medicare |
$72.91
|
|
|
NOREPINEPHRINE 4 MG/250 ML-D5W [VDMC]
|
Facility
|
IP
|
$123.58
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
23229588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$86.51 |
| Max. Negotiated Rate |
$111.22 |
| Rate for Payer: Aetna of IA Commercial |
$111.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$111.22
|
| Rate for Payer: Cash Price |
$98.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$92.69
|
| Rate for Payer: Medical Associates Commercial |
$92.69
|
| Rate for Payer: Midlands Choice Commercial |
$86.51
|
| Rate for Payer: United Healthcare Commercial |
$111.22
|
|
|
nortriptyline 10 mg Cap [VDMC]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10409407
|
|
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
|
|
|
nortriptyline 10 mg Cap [VDMC]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10409407
|
|
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 |
$0.73
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.83
|
|
|
nortriptyline 25 mg Cap [VDMC]
|
Facility
|
IP
|
$1.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10409478
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.94
|
| Rate for Payer: Medical Associates Commercial |
$0.94
|
| Rate for Payer: Midlands Choice Commercial |
$0.87
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
|
|
nortriptyline 25 mg Cap [VDMC]
|
Facility
|
OP
|
$1.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10409478
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Aetna of IA Medicare |
$0.71
|
| Rate for Payer: Amerigroup Medicaid |
$0.72
|
| Rate for Payer: Amerigroup Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.71
|
| Rate for Payer: Medical Associates Commercial |
$0.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.56
|
| Rate for Payer: Midlands Choice Commercial |
$0.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.65
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
|
NOVAFIXPATCH 4x4cm
|
Facility
|
OP
|
$3,960.00
|
|
|
Service Code
|
HCPCS Q4208
|
| Hospital Charge Code |
8822525
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,782.00 |
| Max. Negotiated Rate |
$3,564.00 |
| Rate for Payer: Aetna of IA Commercial |
$3,564.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,564.00
|
| Rate for Payer: Aetna of IA Medicare |
$2,257.20
|
| Rate for Payer: Amerigroup Medicaid |
$2,284.13
|
| Rate for Payer: Amerigroup Medicare |
$1,799.82
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,970.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,782.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,261.95
|
| Rate for Payer: Medical Associates Commercial |
$2,970.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,782.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,772.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,295.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,049.30
|
| Rate for Payer: United Healthcare Commercial |
$3,564.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,336.40
|
|
|
NOVAFIXPATCH 4x4cm
|
Facility
|
IP
|
$3,960.00
|
|
|
Service Code
|
HCPCS Q4208
|
| Hospital Charge Code |
8822525
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,772.00 |
| Max. Negotiated Rate |
$3,564.00 |
| Rate for Payer: Aetna of IA Commercial |
$3,564.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,564.00
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,970.00
|
| Rate for Payer: Medical Associates Commercial |
$2,970.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,772.00
|
| Rate for Payer: United Healthcare Commercial |
$3,564.00
|
|
