|
POST/WASHER TITANIUM 4.5MM X 45MM
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047053
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
POST/WASHER TITANIUM 4.5MM X 47.5MM
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
|
|
POST/WASHER TITANIUM 4.5MM X 47.5MM
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
POST/WASHER TITANIUM 4.5MM X 50MM
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
POST/WASHER TITANIUM 4.5MM X 50MM
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
|
|
POST/WASH TITANIUM 4.5 MM X 52.2MM
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8026402
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
|
|
POST/WASH TITANIUM 4.5 MM X 52.2MM
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8026402
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
POTASSIUM
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
633616
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$39.60 |
| Rate for Payer: Aetna of IA Commercial |
$39.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.60
|
| Rate for Payer: Aetna of IA Medicare |
$25.08
|
| Rate for Payer: Amerigroup Medicaid |
$25.38
|
| Rate for Payer: Amerigroup Medicare |
$20.00
|
| Rate for Payer: Cash Price |
$35.20
|
| Rate for Payer: Cash Price |
$35.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$25.13
|
| Rate for Payer: Medical Associates Commercial |
$33.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.80
|
| Rate for Payer: Midlands Choice Commercial |
$30.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.77
|
| Rate for Payer: United Healthcare Commercial |
$39.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.96
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
POTASSIUM
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
633616
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$39.60 |
| Rate for Payer: Aetna of IA Commercial |
$39.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.60
|
| Rate for Payer: Cash Price |
$35.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.00
|
| Rate for Payer: Medical Associates Commercial |
$33.00
|
| Rate for Payer: Midlands Choice Commercial |
$30.80
|
| Rate for Payer: United Healthcare Commercial |
$39.60
|
|
|
potassium chloride 10 mEq ER Cap [VDMC]
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414460
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of IA Commercial |
$2.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.40
|
| Rate for Payer: Aetna of IA Medicare |
$1.52
|
| Rate for Payer: Amerigroup Medicaid |
$1.54
|
| Rate for Payer: Amerigroup Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.52
|
| Rate for Payer: Medical Associates Commercial |
$2.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.20
|
| Rate for Payer: Midlands Choice Commercial |
$1.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.38
|
| Rate for Payer: United Healthcare Commercial |
$2.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.57
|
|
|
potassium chloride 10 mEq ER Cap [VDMC]
|
Facility
|
IP
|
$2.67
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414460
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of IA Commercial |
$2.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.40
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.00
|
| Rate for Payer: Medical Associates Commercial |
$2.00
|
| Rate for Payer: Midlands Choice Commercial |
$1.87
|
| Rate for Payer: United Healthcare Commercial |
$2.40
|
|
|
potassium chloride 20 mEq/100 mL Bag [VDMC]
|
Facility
|
OP
|
$65.02
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
20402549
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.26 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$58.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.52
|
| Rate for Payer: Aetna of IA Medicare |
$37.06
|
| Rate for Payer: Amerigroup Medicaid |
$37.51
|
| Rate for Payer: Amerigroup Medicare |
$29.55
|
| Rate for Payer: Cash Price |
$52.02
|
| Rate for Payer: Cash Price |
$52.02
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.77
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.14
|
| Rate for Payer: Medical Associates Commercial |
$48.77
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.26
|
| Rate for Payer: Midlands Choice Commercial |
$45.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.65
|
| Rate for Payer: United Healthcare Commercial |
$58.52
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.36
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
potassium chloride 20 mEq/100 mL Bag [VDMC]
|
Facility
|
IP
|
$65.02
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
20402549
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.52 |
| Max. Negotiated Rate |
$58.52 |
| Rate for Payer: Aetna of IA Commercial |
$58.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.52
|
| Rate for Payer: Cash Price |
$52.02
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.77
|
| Rate for Payer: Medical Associates Commercial |
$48.77
|
| Rate for Payer: Midlands Choice Commercial |
$45.52
|
| Rate for Payer: United Healthcare Commercial |
$58.52
|
|
|
potassium chloride 20 mEq/15 mL Oral Liq [VDMC]
|
Facility
|
OP
|
$11.46
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414882
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.16 |
| Max. Negotiated Rate |
$10.32 |
| Rate for Payer: Aetna of IA Commercial |
$10.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.32
|
| Rate for Payer: Aetna of IA Medicare |
$6.53
|
| Rate for Payer: Amerigroup Medicaid |
$6.61
|
| Rate for Payer: Amerigroup Medicare |
$5.21
|
| Rate for Payer: Cash Price |
$9.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.55
|
| Rate for Payer: Medical Associates Commercial |
$8.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.16
|
| Rate for Payer: Midlands Choice Commercial |
$8.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.93
|
| Rate for Payer: United Healthcare Commercial |
$10.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.76
|
|
|
potassium chloride 20 mEq/15 mL Oral Liq [VDMC]
|
Facility
|
IP
|
$11.46
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414882
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.02 |
| Max. Negotiated Rate |
$10.32 |
| Rate for Payer: Aetna of IA Commercial |
$10.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.32
|
| Rate for Payer: Cash Price |
$9.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.60
|
| Rate for Payer: Medical Associates Commercial |
$8.60
|
| Rate for Payer: Midlands Choice Commercial |
$8.02
|
| Rate for Payer: United Healthcare Commercial |
$10.32
|
|
|
potassium chloride 20 mEq ER Tab [VDMC]
|
Facility
|
OP
|
$1.84
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna of IA Commercial |
$1.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.65
|
| Rate for Payer: Aetna of IA Medicare |
$1.05
|
| Rate for Payer: Amerigroup Medicaid |
$1.06
|
| Rate for Payer: Amerigroup Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.83
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.05
|
| Rate for Payer: Medical Associates Commercial |
$1.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.83
|
| Rate for Payer: Midlands Choice Commercial |
$1.29
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.65
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.08
|
|
|
potassium chloride 20 mEq ER Tab [VDMC]
|
Facility
|
IP
|
$1.84
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414744
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna of IA Commercial |
$1.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.65
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.38
|
| Rate for Payer: Medical Associates Commercial |
$1.38
|
| Rate for Payer: Midlands Choice Commercial |
$1.29
|
| Rate for Payer: United Healthcare Commercial |
$1.65
|
|
|
potassium chloride 20 mEq Oral Pwdr [VDMC]
|
Facility
|
IP
|
$9.97
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Aetna of IA Commercial |
$8.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.97
|
| Rate for Payer: Cash Price |
$7.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.48
|
| Rate for Payer: Medical Associates Commercial |
$7.48
|
| Rate for Payer: Midlands Choice Commercial |
$6.98
|
| Rate for Payer: United Healthcare Commercial |
$8.97
|
|
|
potassium chloride 20 mEq Oral Pwdr [VDMC]
|
Facility
|
OP
|
$9.97
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414813
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Aetna of IA Commercial |
$8.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.97
|
| Rate for Payer: Aetna of IA Medicare |
$5.68
|
| Rate for Payer: Amerigroup Medicaid |
$5.75
|
| Rate for Payer: Amerigroup Medicare |
$4.53
|
| Rate for Payer: Cash Price |
$7.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.70
|
| Rate for Payer: Medical Associates Commercial |
$7.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.49
|
| Rate for Payer: Midlands Choice Commercial |
$6.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.16
|
| Rate for Payer: United Healthcare Commercial |
$8.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.88
|
|
|
potassium chloride 2 mEq/mL 10ml SDV [VDMC]
|
Facility
|
IP
|
$23.20
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
10414531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.24 |
| Max. Negotiated Rate |
$20.88 |
| Rate for Payer: Aetna of IA Commercial |
$20.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.88
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.40
|
| Rate for Payer: Medical Associates Commercial |
$17.40
|
| Rate for Payer: Midlands Choice Commercial |
$16.24
|
| Rate for Payer: United Healthcare Commercial |
$20.88
|
|
|
potassium chloride 2 mEq/mL 10ml SDV [VDMC]
|
Facility
|
OP
|
$23.20
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
10414531
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.44 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.88
|
| Rate for Payer: Aetna of IA Medicare |
$13.22
|
| Rate for Payer: Amerigroup Medicaid |
$13.38
|
| Rate for Payer: Amerigroup Medicare |
$10.55
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.40
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.25
|
| Rate for Payer: Medical Associates Commercial |
$17.40
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.44
|
| Rate for Payer: Midlands Choice Commercial |
$16.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.01
|
| Rate for Payer: United Healthcare Commercial |
$20.88
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.69
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
potassium chloride 2 mEq/mL 20ml SDV [VDMC]
|
Facility
|
IP
|
$25.04
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
10414602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.53 |
| Max. Negotiated Rate |
$22.54 |
| Rate for Payer: Aetna of IA Commercial |
$22.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.54
|
| Rate for Payer: Cash Price |
$20.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.78
|
| Rate for Payer: Medical Associates Commercial |
$18.78
|
| Rate for Payer: Midlands Choice Commercial |
$17.53
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
|
|
potassium chloride 2 mEq/mL 20ml SDV [VDMC]
|
Facility
|
OP
|
$25.04
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
10414602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$22.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.54
|
| Rate for Payer: Aetna of IA Medicare |
$14.27
|
| Rate for Payer: Amerigroup Medicaid |
$14.44
|
| Rate for Payer: Amerigroup Medicare |
$11.38
|
| Rate for Payer: Cash Price |
$20.03
|
| Rate for Payer: Cash Price |
$20.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.30
|
| Rate for Payer: Medical Associates Commercial |
$18.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.27
|
| Rate for Payer: Midlands Choice Commercial |
$17.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.96
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.77
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
potassium citrate 10 mEq ER Tab [VDMC]
|
Facility
|
OP
|
$7.91
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414949
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$7.12 |
| Rate for Payer: Aetna of IA Commercial |
$7.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.12
|
| Rate for Payer: Aetna of IA Medicare |
$4.51
|
| Rate for Payer: Amerigroup Medicaid |
$4.56
|
| Rate for Payer: Amerigroup Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$6.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.52
|
| Rate for Payer: Medical Associates Commercial |
$5.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.56
|
| Rate for Payer: Midlands Choice Commercial |
$5.54
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.10
|
| Rate for Payer: United Healthcare Commercial |
$7.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.67
|
|
|
potassium citrate 10 mEq ER Tab [VDMC]
|
Facility
|
IP
|
$7.91
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10414949
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$7.12 |
| Rate for Payer: Aetna of IA Commercial |
$7.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.12
|
| Rate for Payer: Cash Price |
$6.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.94
|
| Rate for Payer: Medical Associates Commercial |
$5.94
|
| Rate for Payer: Midlands Choice Commercial |
$5.54
|
| Rate for Payer: United Healthcare Commercial |
$7.12
|
|
