|
SLITTING OF PREPUCE
|
Facility
|
IP
|
$1,194.00
|
|
|
Service Code
|
CPT 54001
|
| Hospital Charge Code |
7982916
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$835.80 |
| Max. Negotiated Rate |
$1,074.60 |
| Rate for Payer: Aetna of IA Commercial |
$1,074.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,074.60
|
| Rate for Payer: Cash Price |
$955.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$895.50
|
| Rate for Payer: Medical Associates Commercial |
$895.50
|
| Rate for Payer: Midlands Choice Commercial |
$835.80
|
| Rate for Payer: United Healthcare Commercial |
$1,074.60
|
|
|
SLITTING OF PREPUCE
|
Facility
|
OP
|
$1,194.00
|
|
|
Service Code
|
CPT 54001
|
| Hospital Charge Code |
7982916
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$537.30 |
| Max. Negotiated Rate |
$3,601.97 |
| Rate for Payer: Aetna of IA Commercial |
$1,074.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,074.60
|
| Rate for Payer: Aetna of IA Medicare |
$680.58
|
| Rate for Payer: Amerigroup Medicaid |
$688.70
|
| Rate for Payer: Amerigroup Medicare |
$542.67
|
| Rate for Payer: Cash Price |
$955.20
|
| Rate for Payer: Cash Price |
$955.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$895.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$537.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$682.01
|
| Rate for Payer: Medical Associates Commercial |
$895.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$537.30
|
| Rate for Payer: Midlands Choice Commercial |
$835.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$692.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$617.90
|
| Rate for Payer: United Healthcare Commercial |
$1,074.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$704.46
|
| Rate for Payer: Wellmark IA HMO WHPI |
$3,269.91
|
| Rate for Payer: Wellmark IA PPO |
$3,601.97
|
|
|
SLP Eval of Speech Sound Prod Units
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
CPT 92522
|
| Hospital Charge Code |
5528784
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$103.50 |
| Max. Negotiated Rate |
$228.83 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Aetna of IA Medicare |
$131.10
|
| Rate for Payer: Amerigroup Medicaid |
$132.66
|
| Rate for Payer: Amerigroup Medicare |
$104.54
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$103.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$131.38
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$103.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$133.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$119.02
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$135.70
|
| Rate for Payer: Wellmark IA HMO WHPI |
$207.74
|
| Rate for Payer: Wellmark IA PPO |
$228.83
|
|
|
SLP Eval of Speech Sound Prod Units
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
CPT 92522
|
| Hospital Charge Code |
5528784
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of IA Commercial |
$207.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$207.00
|
| Rate for Payer: Cash Price |
$184.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$172.50
|
| Rate for Payer: Medical Associates Commercial |
$172.50
|
| Rate for Payer: Midlands Choice Commercial |
$161.00
|
| Rate for Payer: United Healthcare Commercial |
$207.00
|
|
|
SMALL VLC PLATE RIGHT
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8700302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,260.00 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,620.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,620.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,350.00
|
| Rate for Payer: Medical Associates Commercial |
$1,350.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,260.00
|
| Rate for Payer: United Healthcare Commercial |
$1,620.00
|
|
|
SMALL VLC PLATE RIGHT
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8700302
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$810.00 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,620.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,620.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,026.00
|
| Rate for Payer: Amerigroup Medicaid |
$1,038.24
|
| Rate for Payer: Amerigroup Medicare |
$818.10
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,350.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$810.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,028.16
|
| Rate for Payer: Medical Associates Commercial |
$1,350.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$810.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,260.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,043.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$931.50
|
| Rate for Payer: United Healthcare Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,062.00
|
|
|
Smooth Muscle Antibody DMCL
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
8037802
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of IA Commercial |
$103.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.50
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.25
|
| Rate for Payer: Medical Associates Commercial |
$86.25
|
| Rate for Payer: Midlands Choice Commercial |
$80.50
|
| Rate for Payer: United Healthcare Commercial |
$103.50
|
|
|
Smooth Muscle Antibody DMCL
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
8037802
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$41.83 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of IA Commercial |
$103.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.50
|
| Rate for Payer: Aetna of IA Medicare |
$65.55
|
| Rate for Payer: Amerigroup Medicaid |
$66.33
|
| Rate for Payer: Amerigroup Medicare |
$52.27
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.69
|
| Rate for Payer: Medical Associates Commercial |
$86.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.75
|
| Rate for Payer: Midlands Choice Commercial |
$80.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$59.51
|
| Rate for Payer: United Healthcare Commercial |
$103.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.85
|
| Rate for Payer: Wellmark IA HMO WHPI |
$41.83
|
| Rate for Payer: Wellmark IA PPO |
$46.08
|
|
|
SNIPER STAPLE 18MMX18MMX18MM
|
Facility
|
OP
|
$1,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8713571
|
|
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 18MMX18MMX18MM
|
Facility
|
IP
|
$1,710.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8713571
|
|
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 10X10X10
|
Facility
|
OP
|
$2,520.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8734824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,134.00 |
| Max. Negotiated Rate |
$2,268.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,268.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,268.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,436.40
|
| Rate for Payer: Amerigroup Medicaid |
$1,453.54
|
| Rate for Payer: Amerigroup Medicare |
$1,145.34
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,890.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,134.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,439.42
|
| Rate for Payer: Medical Associates Commercial |
$1,890.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,134.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,764.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,460.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,304.10
|
| Rate for Payer: United Healthcare Commercial |
$2,268.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,486.80
|
|
|
SNIPER STAPLE IMPLANT 10X10X10
|
Facility
|
IP
|
$2,520.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8734824
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,764.00 |
| Max. Negotiated Rate |
$2,268.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,268.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,268.00
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,890.00
|
| Rate for Payer: Medical Associates Commercial |
$1,890.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,764.00
|
| Rate for Payer: United Healthcare Commercial |
$2,268.00
|
|
|
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
|
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 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 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
|
|
|
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
|
|
|
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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$30.49
|
| Rate for Payer: Wellmark IA PPO |
$33.58
|
|
|
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
|
|
