|
SNIPER STAPLE IMPLANT 15X15X15
|
Facility
|
IP
|
$1,629.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8852333
|
|
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
|
|
|
SNIPER STAPLE IMPLANT 15X15X15
|
Facility
|
OP
|
$1,629.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8852333
|
|
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
|
|
|
SNIPER STAPLE IMPLANT 20X20X20MM
|
Facility
|
IP
|
$1,710.00
|
|
| Hospital Charge Code |
8783240
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,197.00 |
| Max. Negotiated Rate |
$1,539.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,539.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,539.00
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,282.50
|
| Rate for Payer: Medical Associates Commercial |
$1,282.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,197.00
|
| Rate for Payer: United Healthcare Commercial |
$1,539.00
|
|
|
SNIPER STAPLE IMPLANT 20X20X20MM
|
Facility
|
OP
|
$1,710.00
|
|
| Hospital Charge Code |
8783240
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$769.50 |
| Max. Negotiated Rate |
$1,539.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,539.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,539.00
|
| Rate for Payer: Aetna of IA Medicare |
$974.70
|
| Rate for Payer: Amerigroup Medicaid |
$986.33
|
| Rate for Payer: Amerigroup Medicare |
$777.20
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,282.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$769.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$976.75
|
| Rate for Payer: Medical Associates Commercial |
$1,282.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$769.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,197.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$991.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$884.92
|
| Rate for Payer: United Healthcare Commercial |
$1,539.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,008.90
|
|
|
SNIPER STAPLE IMPLANT 25X20X20MM
|
Facility
|
OP
|
$1,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8783242
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$769.50 |
| Max. Negotiated Rate |
$1,539.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,539.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,539.00
|
| Rate for Payer: Aetna of IA Medicare |
$974.70
|
| Rate for Payer: Amerigroup Medicaid |
$986.33
|
| Rate for Payer: Amerigroup Medicare |
$777.20
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,282.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$769.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$976.75
|
| Rate for Payer: Medical Associates Commercial |
$1,282.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$769.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,197.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$991.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$884.92
|
| Rate for Payer: United Healthcare Commercial |
$1,539.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,008.90
|
|
|
SNIPER STAPLE IMPLANT 25X20X20MM
|
Facility
|
IP
|
$1,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8783242
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,197.00 |
| Max. Negotiated Rate |
$1,539.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,539.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,539.00
|
| Rate for Payer: Cash Price |
$1,368.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,282.50
|
| Rate for Payer: Medical Associates Commercial |
$1,282.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,197.00
|
| Rate for Payer: United Healthcare Commercial |
$1,539.00
|
|
|
SODIUM
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna of IA Commercial |
$41.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$41.40
|
| Rate for Payer: Cash Price |
$36.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$34.50
|
| Rate for Payer: Medical Associates Commercial |
$34.50
|
| Rate for Payer: Midlands Choice Commercial |
$32.20
|
| Rate for Payer: United Healthcare Commercial |
$41.40
|
|
|
SODIUM
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna of IA Commercial |
$41.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$41.40
|
| Rate for Payer: Aetna of IA Medicare |
$26.22
|
| Rate for Payer: Amerigroup Medicaid |
$26.53
|
| Rate for Payer: Amerigroup Medicare |
$20.91
|
| Rate for Payer: Cash Price |
$36.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$34.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.28
|
| Rate for Payer: Medical Associates Commercial |
$34.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.70
|
| Rate for Payer: Midlands Choice Commercial |
$32.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.80
|
| Rate for Payer: United Healthcare Commercial |
$41.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$27.14
|
|
|
sodium bicarbonate 4.2% IV Sol 10 mL [VDMC]
|
Facility
|
IP
|
$62.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10421208
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$43.85 |
| Max. Negotiated Rate |
$56.38 |
| Rate for Payer: Aetna of IA Commercial |
$56.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.38
|
| Rate for Payer: Cash Price |
$50.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.99
|
| Rate for Payer: Medical Associates Commercial |
$46.99
|
| Rate for Payer: Midlands Choice Commercial |
$43.85
|
| Rate for Payer: United Healthcare Commercial |
$56.38
|
|
|
sodium bicarbonate 4.2% IV Sol 10 mL [VDMC]
|
Facility
|
OP
|
$62.65
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10421208
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.19 |
| Max. Negotiated Rate |
$56.38 |
| Rate for Payer: Aetna of IA Commercial |
$56.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.38
|
| Rate for Payer: Aetna of IA Medicare |
$35.71
|
| Rate for Payer: Amerigroup Medicaid |
$36.14
|
| Rate for Payer: Amerigroup Medicare |
$28.47
|
| Rate for Payer: Cash Price |
$50.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.99
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.19
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.78
|
| Rate for Payer: Medical Associates Commercial |
$46.99
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.19
|
| Rate for Payer: Midlands Choice Commercial |
$43.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.42
|
| Rate for Payer: United Healthcare Commercial |
$56.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.96
|
|
|
sodium bicarbonate 4.2% IV Sol 5 mL SDV [VDMC]
|
Facility
|
OP
|
$50.16
|
|
|
Service Code
|
NDC 63323-0083-05
|
| Hospital Charge Code |
10437956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.57 |
| Max. Negotiated Rate |
$45.15 |
| Rate for Payer: Aetna of IA Commercial |
$45.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.15
|
| Rate for Payer: Aetna of IA Medicare |
$28.59
|
| Rate for Payer: Amerigroup Medicaid |
$28.94
|
| Rate for Payer: Amerigroup Medicare |
$22.80
|
| Rate for Payer: Cash Price |
$40.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.65
|
| Rate for Payer: Medical Associates Commercial |
$37.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.57
|
| Rate for Payer: Midlands Choice Commercial |
$35.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$25.96
|
| Rate for Payer: United Healthcare Commercial |
$45.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$29.60
|
|
|
sodium bicarbonate 4.2% IV Sol 5 mL SDV [VDMC]
|
Facility
|
IP
|
$50.16
|
|
|
Service Code
|
NDC 63323-0083-05
|
| Hospital Charge Code |
10437956
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.12 |
| Max. Negotiated Rate |
$45.15 |
| Rate for Payer: Aetna of IA Commercial |
$45.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.15
|
| Rate for Payer: Cash Price |
$40.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.62
|
| Rate for Payer: Medical Associates Commercial |
$37.62
|
| Rate for Payer: Midlands Choice Commercial |
$35.12
|
| Rate for Payer: United Healthcare Commercial |
$45.15
|
|
|
sodium bicarbonate 650 mg Tab [VDMC]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421275
|
|
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 |
$0.56
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.93
|
| 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 |
$0.93
|
| 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 |
$0.64
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.73
|
|
|
sodium bicarbonate 650 mg Tab [VDMC]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421275
|
|
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 |
$0.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.93
|
| Rate for Payer: Medical Associates Commercial |
$0.93
|
| Rate for Payer: Midlands Choice Commercial |
$0.87
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
|
|
sodium bicarbonate 8.4% 50ml Syringe[VDMC]
|
Facility
|
IP
|
$60.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
14019421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.31 |
| Max. Negotiated Rate |
$54.40 |
| Rate for Payer: Aetna of IA Commercial |
$54.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.40
|
| Rate for Payer: Cash Price |
$48.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.33
|
| Rate for Payer: Medical Associates Commercial |
$45.33
|
| Rate for Payer: Midlands Choice Commercial |
$42.31
|
| Rate for Payer: United Healthcare Commercial |
$54.40
|
|
|
sodium bicarbonate 8.4% 50ml Syringe[VDMC]
|
Facility
|
OP
|
$60.44
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
14019421
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$54.40 |
| Rate for Payer: Aetna of IA Commercial |
$54.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.40
|
| Rate for Payer: Aetna of IA Medicare |
$34.45
|
| Rate for Payer: Amerigroup Medicaid |
$34.86
|
| Rate for Payer: Amerigroup Medicare |
$27.47
|
| Rate for Payer: Cash Price |
$48.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$34.53
|
| Rate for Payer: Medical Associates Commercial |
$45.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.20
|
| Rate for Payer: Midlands Choice Commercial |
$42.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.28
|
| Rate for Payer: United Healthcare Commercial |
$54.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.66
|
|
|
sodium bicarbonate 8.4% IV 50 mL Vial [VDMC]
|
Facility
|
IP
|
$38.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10421344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.19 |
| Max. Negotiated Rate |
$34.96 |
| Rate for Payer: Aetna of IA Commercial |
$34.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.96
|
| Rate for Payer: Cash Price |
$31.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$29.13
|
| Rate for Payer: Medical Associates Commercial |
$29.13
|
| Rate for Payer: Midlands Choice Commercial |
$27.19
|
| Rate for Payer: United Healthcare Commercial |
$34.96
|
|
|
sodium bicarbonate 8.4% IV 50 mL Vial [VDMC]
|
Facility
|
OP
|
$38.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10421344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.48 |
| Max. Negotiated Rate |
$34.96 |
| Rate for Payer: Aetna of IA Commercial |
$34.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.96
|
| Rate for Payer: Aetna of IA Medicare |
$22.14
|
| Rate for Payer: Amerigroup Medicaid |
$22.40
|
| Rate for Payer: Amerigroup Medicare |
$17.65
|
| Rate for Payer: Cash Price |
$31.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$29.13
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.19
|
| Rate for Payer: Medical Associates Commercial |
$29.13
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.48
|
| Rate for Payer: Midlands Choice Commercial |
$27.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.10
|
| Rate for Payer: United Healthcare Commercial |
$34.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.92
|
|
|
Sodium Chloride 0.45% IV Sol 1000 mL [VDMC]
|
Facility
|
OP
|
$67.12
|
|
|
Service Code
|
NDC 00338-0043-04
|
| Hospital Charge Code |
10441171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.20 |
| Max. Negotiated Rate |
$60.41 |
| Rate for Payer: Aetna of IA Commercial |
$60.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.41
|
| Rate for Payer: Aetna of IA Medicare |
$38.26
|
| Rate for Payer: Amerigroup Medicaid |
$38.71
|
| Rate for Payer: Amerigroup Medicare |
$30.51
|
| Rate for Payer: Cash Price |
$53.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.34
|
| Rate for Payer: Medical Associates Commercial |
$50.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.20
|
| Rate for Payer: Midlands Choice Commercial |
$46.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.73
|
| Rate for Payer: United Healthcare Commercial |
$60.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.60
|
|
|
Sodium Chloride 0.45% IV Sol 1000 mL [VDMC]
|
Facility
|
IP
|
$67.12
|
|
|
Service Code
|
NDC 00338-0043-04
|
| Hospital Charge Code |
10441171
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.98 |
| Max. Negotiated Rate |
$60.41 |
| Rate for Payer: Aetna of IA Commercial |
$60.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.41
|
| Rate for Payer: Cash Price |
$53.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.34
|
| Rate for Payer: Medical Associates Commercial |
$50.34
|
| Rate for Payer: Midlands Choice Commercial |
$46.98
|
| Rate for Payer: United Healthcare Commercial |
$60.41
|
|
|
Sodium Chloride 0.45% with KCl 20 mEq/L intravenous solution Sodium Chloride 0.45% with KCl 20 mEq/L Sol [VDMC]
|
Facility
|
OP
|
$59.32
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11220446
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.69 |
| Max. Negotiated Rate |
$53.39 |
| Rate for Payer: Aetna of IA Commercial |
$53.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$53.39
|
| Rate for Payer: Aetna of IA Medicare |
$33.81
|
| Rate for Payer: Amerigroup Medicaid |
$34.22
|
| Rate for Payer: Amerigroup Medicare |
$26.96
|
| Rate for Payer: Cash Price |
$47.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$44.49
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.69
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.88
|
| Rate for Payer: Medical Associates Commercial |
$44.49
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.69
|
| Rate for Payer: Midlands Choice Commercial |
$41.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$34.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.70
|
| Rate for Payer: United Healthcare Commercial |
$53.39
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.00
|
|
|
Sodium Chloride 0.45% with KCl 20 mEq/L intravenous solution Sodium Chloride 0.45% with KCl 20 mEq/L Sol [VDMC]
|
Facility
|
IP
|
$59.32
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11220446
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.52 |
| Max. Negotiated Rate |
$53.39 |
| Rate for Payer: Aetna of IA Commercial |
$53.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$53.39
|
| Rate for Payer: Cash Price |
$47.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$44.49
|
| Rate for Payer: Medical Associates Commercial |
$44.49
|
| Rate for Payer: Midlands Choice Commercial |
$41.52
|
| Rate for Payer: United Healthcare Commercial |
$53.39
|
|
|
Sodium Chloride 0.9% 100 mL IV Sol [VDMC]
|
Facility
|
IP
|
$65.88
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
11088778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.12 |
| Max. Negotiated Rate |
$59.29 |
| Rate for Payer: Aetna of IA Commercial |
$59.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.29
|
| Rate for Payer: Cash Price |
$52.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.41
|
| Rate for Payer: Medical Associates Commercial |
$49.41
|
| Rate for Payer: Midlands Choice Commercial |
$46.12
|
| Rate for Payer: United Healthcare Commercial |
$59.29
|
|
|
Sodium Chloride 0.9% 100 mL IV Sol [VDMC]
|
Facility
|
OP
|
$65.88
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
11088778
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.65 |
| Max. Negotiated Rate |
$59.29 |
| Rate for Payer: Aetna of IA Commercial |
$59.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.29
|
| Rate for Payer: Aetna of IA Medicare |
$37.55
|
| Rate for Payer: Amerigroup Medicaid |
$38.00
|
| Rate for Payer: Amerigroup Medicare |
$29.94
|
| Rate for Payer: Cash Price |
$52.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.41
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.63
|
| Rate for Payer: Medical Associates Commercial |
$49.41
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.65
|
| Rate for Payer: Midlands Choice Commercial |
$46.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.09
|
| Rate for Payer: United Healthcare Commercial |
$59.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.87
|
|
|
Sodium Chloride 0.9% 500 ml intravenous solution [VDMC]
|
Facility
|
IP
|
$66.70
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
10605618
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.69 |
| Max. Negotiated Rate |
$60.03 |
| Rate for Payer: Aetna of IA Commercial |
$60.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.03
|
| Rate for Payer: Cash Price |
$53.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.02
|
| Rate for Payer: Medical Associates Commercial |
$50.02
|
| Rate for Payer: Midlands Choice Commercial |
$46.69
|
| Rate for Payer: United Healthcare Commercial |
$60.03
|
|
