|
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
|
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 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 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
|
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 0.45% 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 |
$221.80 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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 |
$221.80 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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% 500 ml intravenous solution [VDMC]
|
Facility
|
OP
|
$66.70
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
10605618
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.02 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$60.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.03
|
| Rate for Payer: Aetna of IA Medicare |
$38.02
|
| Rate for Payer: Amerigroup Medicaid |
$38.47
|
| Rate for Payer: Amerigroup Medicare |
$30.32
|
| Rate for Payer: Cash Price |
$53.36
|
| Rate for Payer: Cash Price |
$53.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.10
|
| Rate for Payer: Medical Associates Commercial |
$50.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.02
|
| Rate for Payer: Midlands Choice Commercial |
$46.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.52
|
| Rate for Payer: United Healthcare Commercial |
$60.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.35
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
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
|
|
|
sodium chloride 0.9% Inh Sol 3 mL [VDMC]
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 76204-0300-03
|
| Hospital Charge Code |
10438086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna of IA Commercial |
$4.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.21
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.51
|
| Rate for Payer: Medical Associates Commercial |
$3.51
|
| Rate for Payer: Midlands Choice Commercial |
$3.27
|
| Rate for Payer: United Healthcare Commercial |
$4.21
|
|
|
sodium chloride 0.9% Inh Sol 3 mL [VDMC]
|
Facility
|
OP
|
$4.68
|
|
|
Service Code
|
NDC 76204-0300-03
|
| Hospital Charge Code |
10438086
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna of IA Commercial |
$4.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.21
|
| Rate for Payer: Aetna of IA Medicare |
$2.67
|
| Rate for Payer: Amerigroup Medicaid |
$2.70
|
| Rate for Payer: Amerigroup Medicare |
$2.13
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.67
|
| Rate for Payer: Medical Associates Commercial |
$3.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.10
|
| Rate for Payer: Midlands Choice Commercial |
$3.27
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.42
|
| Rate for Payer: United Healthcare Commercial |
$4.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.76
|
|
|
Sodium Chloride 0.9% intravenous solution 25 mL [VDMC]
|
Facility
|
IP
|
$63.66
|
|
|
Service Code
|
NDC 00409-7984-20
|
| Hospital Charge Code |
11089158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.56 |
| Max. Negotiated Rate |
$57.29 |
| Rate for Payer: Aetna of IA Commercial |
$57.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.29
|
| Rate for Payer: Cash Price |
$50.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.74
|
| Rate for Payer: Medical Associates Commercial |
$47.74
|
| Rate for Payer: Midlands Choice Commercial |
$44.56
|
| Rate for Payer: United Healthcare Commercial |
$57.29
|
|
|
Sodium Chloride 0.9% intravenous solution 25 mL [VDMC]
|
Facility
|
OP
|
$63.66
|
|
|
Service Code
|
NDC 00409-7984-20
|
| Hospital Charge Code |
11089158
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.64 |
| Max. Negotiated Rate |
$57.29 |
| Rate for Payer: Aetna of IA Commercial |
$57.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.29
|
| Rate for Payer: Aetna of IA Medicare |
$36.28
|
| Rate for Payer: Amerigroup Medicaid |
$36.72
|
| Rate for Payer: Amerigroup Medicare |
$28.93
|
| Rate for Payer: Cash Price |
$50.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.74
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$36.36
|
| Rate for Payer: Medical Associates Commercial |
$47.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.64
|
| Rate for Payer: Midlands Choice Commercial |
$44.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.94
|
| Rate for Payer: United Healthcare Commercial |
$57.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.56
|
|
|
Sodium Chloride 0.9% IV Sol 1000 mL [VDMC]
|
Facility
|
IP
|
$66.80
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
10441371
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$60.12 |
| Rate for Payer: Aetna of IA Commercial |
$60.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.12
|
| Rate for Payer: Cash Price |
$53.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.10
|
| Rate for Payer: Medical Associates Commercial |
$50.10
|
| Rate for Payer: Midlands Choice Commercial |
$46.76
|
| Rate for Payer: United Healthcare Commercial |
$60.12
|
|
|
Sodium Chloride 0.9% IV Sol 1000 mL [VDMC]
|
Facility
|
OP
|
$66.80
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
10441371
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.06 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$60.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.12
|
| Rate for Payer: Aetna of IA Medicare |
$38.08
|
| Rate for Payer: Amerigroup Medicaid |
$38.53
|
| Rate for Payer: Amerigroup Medicare |
$30.36
|
| Rate for Payer: Cash Price |
$53.44
|
| Rate for Payer: Cash Price |
$53.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.16
|
| Rate for Payer: Medical Associates Commercial |
$50.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.06
|
| Rate for Payer: Midlands Choice Commercial |
$46.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.57
|
| Rate for Payer: United Healthcare Commercial |
$60.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.41
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
Sodium Chloride 0.9% IV Sol 250 mL [VDMC]
|
Facility
|
OP
|
$65.26
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
10441438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.37 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$58.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.73
|
| Rate for Payer: Aetna of IA Medicare |
$37.20
|
| Rate for Payer: Amerigroup Medicaid |
$37.64
|
| Rate for Payer: Amerigroup Medicare |
$29.66
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.37
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.28
|
| Rate for Payer: Medical Associates Commercial |
$48.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.37
|
| Rate for Payer: Midlands Choice Commercial |
$45.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.77
|
| Rate for Payer: United Healthcare Commercial |
$58.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.50
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
Sodium Chloride 0.9% IV Sol 250 mL [VDMC]
|
Facility
|
IP
|
$65.26
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
10441438
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.68 |
| Max. Negotiated Rate |
$58.73 |
| Rate for Payer: Aetna of IA Commercial |
$58.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.73
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.94
|
| Rate for Payer: Medical Associates Commercial |
$48.94
|
| Rate for Payer: Midlands Choice Commercial |
$45.68
|
| Rate for Payer: United Healthcare Commercial |
$58.73
|
|
|
Sodium Chloride 0.9% IV Sol 50 mL [VDMC]
|
Facility
|
OP
|
$66.80
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
10441505
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.06 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$60.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.12
|
| Rate for Payer: Aetna of IA Medicare |
$38.07
|
| Rate for Payer: Amerigroup Medicaid |
$38.53
|
| Rate for Payer: Amerigroup Medicare |
$30.36
|
| Rate for Payer: Cash Price |
$53.44
|
| Rate for Payer: Cash Price |
$53.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.15
|
| Rate for Payer: Medical Associates Commercial |
$50.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.06
|
| Rate for Payer: Midlands Choice Commercial |
$46.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.57
|
| Rate for Payer: United Healthcare Commercial |
$60.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.41
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
Sodium Chloride 0.9% IV Sol 50 mL [VDMC]
|
Facility
|
IP
|
$66.80
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
10441505
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$60.12 |
| Rate for Payer: Aetna of IA Commercial |
$60.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.12
|
| Rate for Payer: Cash Price |
$53.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.10
|
| Rate for Payer: Medical Associates Commercial |
$50.10
|
| Rate for Payer: Midlands Choice Commercial |
$46.76
|
| Rate for Payer: United Healthcare Commercial |
$60.12
|
|
|
sodium chloride 1 g Tab [VDMC]
|
Facility
|
IP
|
$1.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna of IA Commercial |
$1.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.15
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.96
|
| Rate for Payer: Medical Associates Commercial |
$0.96
|
| Rate for Payer: Midlands Choice Commercial |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$1.15
|
|
|
sodium chloride 1 g Tab [VDMC]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Aetna of IA Commercial |
$1.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.15
|
| Rate for Payer: Aetna of IA Medicare |
$0.73
|
| Rate for Payer: Amerigroup Medicaid |
$0.74
|
| Rate for Payer: Amerigroup Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.96
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.73
|
| Rate for Payer: Medical Associates Commercial |
$0.96
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.66
|
| Rate for Payer: United Healthcare Commercial |
$1.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.76
|
|
