|
sodium chloride 3% neb Sol 4 ml SDV [VDMC]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 00487-9003-60
|
| Hospital Charge Code |
12710834
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna of IA Commercial |
$4.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.62
|
| Rate for Payer: Aetna of IA Medicare |
$2.92
|
| Rate for Payer: Amerigroup Medicaid |
$2.96
|
| Rate for Payer: Amerigroup Medicare |
$2.33
|
| Rate for Payer: Cash Price |
$4.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.31
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.93
|
| Rate for Payer: Medical Associates Commercial |
$3.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.31
|
| Rate for Payer: Midlands Choice Commercial |
$3.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.65
|
| Rate for Payer: United Healthcare Commercial |
$4.62
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.03
|
|
|
sodium chloride 3% neb Sol 4 ml SDV [VDMC]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 00487-9003-60
|
| Hospital Charge Code |
12710834
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna of IA Commercial |
$4.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.62
|
| Rate for Payer: Cash Price |
$4.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.85
|
| Rate for Payer: Medical Associates Commercial |
$3.85
|
| Rate for Payer: Midlands Choice Commercial |
$3.59
|
| Rate for Payer: United Healthcare Commercial |
$4.62
|
|
|
sodium chloride 7% UD neb sol 4ml SDV [VDMC]
|
Facility
|
IP
|
$6.33
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
17985180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Aetna of IA Commercial |
$5.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.70
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.75
|
| Rate for Payer: Medical Associates Commercial |
$4.75
|
| Rate for Payer: Midlands Choice Commercial |
$4.43
|
| Rate for Payer: United Healthcare Commercial |
$5.70
|
|
|
sodium chloride 7% UD neb sol 4ml SDV [VDMC]
|
Facility
|
OP
|
$6.33
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
17985180
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Aetna of IA Commercial |
$5.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.70
|
| Rate for Payer: Aetna of IA Medicare |
$3.61
|
| Rate for Payer: Amerigroup Medicaid |
$3.65
|
| Rate for Payer: Amerigroup Medicare |
$2.88
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.62
|
| Rate for Payer: Medical Associates Commercial |
$4.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.85
|
| Rate for Payer: Midlands Choice Commercial |
$4.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.28
|
| Rate for Payer: United Healthcare Commercial |
$5.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.74
|
|
|
Sodium Chloride HYPERTONIC 3% IV Sol 500 mL [VDMC]
|
Facility
|
IP
|
$67.18
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
10441689
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.03 |
| Max. Negotiated Rate |
$60.46 |
| Rate for Payer: Aetna of IA Commercial |
$60.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.46
|
| Rate for Payer: Cash Price |
$53.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.38
|
| Rate for Payer: Medical Associates Commercial |
$50.38
|
| Rate for Payer: Midlands Choice Commercial |
$47.03
|
| Rate for Payer: United Healthcare Commercial |
$60.46
|
|
|
Sodium Chloride HYPERTONIC 3% IV Sol 500 mL [VDMC]
|
Facility
|
OP
|
$67.18
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
10441689
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.23 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$60.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.46
|
| Rate for Payer: Aetna of IA Medicare |
$38.29
|
| Rate for Payer: Amerigroup Medicaid |
$38.75
|
| Rate for Payer: Amerigroup Medicare |
$30.53
|
| Rate for Payer: Cash Price |
$53.74
|
| Rate for Payer: Cash Price |
$53.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.23
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.37
|
| Rate for Payer: Medical Associates Commercial |
$50.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.23
|
| Rate for Payer: Midlands Choice Commercial |
$47.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.77
|
| Rate for Payer: United Healthcare Commercial |
$60.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.64
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
sodium chloride, hypertonic, Ophth 5% Sol [VDMC]
|
Facility
|
IP
|
$49.80
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10439002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.86 |
| Max. Negotiated Rate |
$44.82 |
| Rate for Payer: Aetna of IA Commercial |
$44.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.82
|
| Rate for Payer: Cash Price |
$39.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.35
|
| Rate for Payer: Medical Associates Commercial |
$37.35
|
| Rate for Payer: Midlands Choice Commercial |
$34.86
|
| Rate for Payer: United Healthcare Commercial |
$44.82
|
|
|
sodium chloride, hypertonic, Ophth 5% Sol [VDMC]
|
Facility
|
OP
|
$49.80
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10439002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.41 |
| Max. Negotiated Rate |
$44.82 |
| Rate for Payer: Aetna of IA Commercial |
$44.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.82
|
| Rate for Payer: Aetna of IA Medicare |
$28.39
|
| Rate for Payer: Amerigroup Medicaid |
$28.72
|
| Rate for Payer: Amerigroup Medicare |
$22.63
|
| Rate for Payer: Cash Price |
$39.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.45
|
| Rate for Payer: Medical Associates Commercial |
$37.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.41
|
| Rate for Payer: Midlands Choice Commercial |
$34.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$28.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$25.77
|
| Rate for Payer: United Healthcare Commercial |
$44.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$29.38
|
|
|
sodium chloride nasal 0.65% Gel [VDMC]
|
Facility
|
IP
|
$27.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10438811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.07 |
| Max. Negotiated Rate |
$24.52 |
| Rate for Payer: Aetna of IA Commercial |
$24.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.52
|
| Rate for Payer: Cash Price |
$21.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.43
|
| Rate for Payer: Medical Associates Commercial |
$20.43
|
| Rate for Payer: Midlands Choice Commercial |
$19.07
|
| Rate for Payer: United Healthcare Commercial |
$24.52
|
|
|
sodium chloride nasal 0.65% Gel [VDMC]
|
Facility
|
OP
|
$27.24
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10438811
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.26 |
| Max. Negotiated Rate |
$24.52 |
| Rate for Payer: Aetna of IA Commercial |
$24.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.52
|
| Rate for Payer: Aetna of IA Medicare |
$15.53
|
| Rate for Payer: Amerigroup Medicaid |
$15.71
|
| Rate for Payer: Amerigroup Medicare |
$12.38
|
| Rate for Payer: Cash Price |
$21.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.56
|
| Rate for Payer: Medical Associates Commercial |
$20.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.26
|
| Rate for Payer: Midlands Choice Commercial |
$19.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.10
|
| Rate for Payer: United Healthcare Commercial |
$24.52
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.07
|
|
|
sodium chloride Nasal 0.65% Spry [VDMC]
|
Facility
|
OP
|
$18.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10438876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.12 |
| Max. Negotiated Rate |
$16.24 |
| Rate for Payer: Aetna of IA Commercial |
$16.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.24
|
| Rate for Payer: Aetna of IA Medicare |
$10.28
|
| Rate for Payer: Amerigroup Medicaid |
$10.41
|
| Rate for Payer: Amerigroup Medicare |
$8.20
|
| Rate for Payer: Cash Price |
$14.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.53
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.30
|
| Rate for Payer: Medical Associates Commercial |
$13.53
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.12
|
| Rate for Payer: Midlands Choice Commercial |
$12.63
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.34
|
| Rate for Payer: United Healthcare Commercial |
$16.24
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.64
|
|
|
sodium chloride Nasal 0.65% Spry [VDMC]
|
Facility
|
IP
|
$18.04
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10438876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.63 |
| Max. Negotiated Rate |
$16.24 |
| Rate for Payer: Aetna of IA Commercial |
$16.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.24
|
| Rate for Payer: Cash Price |
$14.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.53
|
| Rate for Payer: Medical Associates Commercial |
$13.53
|
| Rate for Payer: Midlands Choice Commercial |
$12.63
|
| Rate for Payer: United Healthcare Commercial |
$16.24
|
|
|
sodium hypochlorite 0.125% topical soln [VDMC]
|
Facility
|
IP
|
$65.53
|
|
|
Service Code
|
NDC 00436-0672-16
|
| Hospital Charge Code |
10439067
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.87 |
| Max. Negotiated Rate |
$58.97 |
| Rate for Payer: Aetna of IA Commercial |
$58.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.97
|
| Rate for Payer: Cash Price |
$52.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.14
|
| Rate for Payer: Medical Associates Commercial |
$49.14
|
| Rate for Payer: Midlands Choice Commercial |
$45.87
|
| Rate for Payer: United Healthcare Commercial |
$58.97
|
|
|
sodium hypochlorite 0.125% topical soln [VDMC]
|
Facility
|
OP
|
$65.53
|
|
|
Service Code
|
NDC 00436-0672-16
|
| Hospital Charge Code |
10439067
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.49 |
| Max. Negotiated Rate |
$58.97 |
| Rate for Payer: Aetna of IA Commercial |
$58.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.97
|
| Rate for Payer: Aetna of IA Medicare |
$37.35
|
| Rate for Payer: Amerigroup Medicaid |
$37.79
|
| Rate for Payer: Amerigroup Medicare |
$29.78
|
| Rate for Payer: Cash Price |
$52.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.43
|
| Rate for Payer: Medical Associates Commercial |
$49.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.49
|
| Rate for Payer: Midlands Choice Commercial |
$45.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.91
|
| Rate for Payer: United Healthcare Commercial |
$58.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.66
|
|
|
Sodium-K+-Mag-CA-Chlor-Acetate IV Sol 20 mL [VDMC]
|
Facility
|
OP
|
$57.05
|
|
|
Service Code
|
NDC 00409-5779-01
|
| Hospital Charge Code |
10401994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.67 |
| Max. Negotiated Rate |
$51.34 |
| Rate for Payer: Aetna of IA Commercial |
$51.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.34
|
| Rate for Payer: Aetna of IA Medicare |
$32.52
|
| Rate for Payer: Amerigroup Medicaid |
$32.91
|
| Rate for Payer: Amerigroup Medicare |
$25.93
|
| Rate for Payer: Cash Price |
$45.64
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.79
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$25.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.59
|
| Rate for Payer: Medical Associates Commercial |
$42.79
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.67
|
| Rate for Payer: Midlands Choice Commercial |
$39.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$29.52
|
| Rate for Payer: United Healthcare Commercial |
$51.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.66
|
|
|
Sodium-K+-Mag-CA-Chlor-Acetate IV Sol 20 mL [VDMC]
|
Facility
|
IP
|
$57.05
|
|
|
Service Code
|
NDC 00409-5779-01
|
| Hospital Charge Code |
10401994
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$39.93 |
| Max. Negotiated Rate |
$51.34 |
| Rate for Payer: Aetna of IA Commercial |
$51.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.34
|
| Rate for Payer: Cash Price |
$45.64
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.79
|
| Rate for Payer: Medical Associates Commercial |
$42.79
|
| Rate for Payer: Midlands Choice Commercial |
$39.93
|
| Rate for Payer: United Healthcare Commercial |
$51.34
|
|
|
Sodium Nitroprusside 25 mg/mL 2ml SDV [VDMC]
|
Facility
|
OP
|
$67.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10409275
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.42 |
| Max. Negotiated Rate |
$60.84 |
| Rate for Payer: Aetna of IA Commercial |
$60.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.84
|
| Rate for Payer: Aetna of IA Medicare |
$38.53
|
| Rate for Payer: Amerigroup Medicaid |
$38.99
|
| Rate for Payer: Amerigroup Medicare |
$30.72
|
| Rate for Payer: Cash Price |
$54.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.61
|
| Rate for Payer: Medical Associates Commercial |
$50.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.42
|
| Rate for Payer: Midlands Choice Commercial |
$47.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$39.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.98
|
| Rate for Payer: United Healthcare Commercial |
$60.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.88
|
|
|
Sodium Nitroprusside 25 mg/mL 2ml SDV [VDMC]
|
Facility
|
IP
|
$67.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10409275
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.32 |
| Max. Negotiated Rate |
$60.84 |
| Rate for Payer: Aetna of IA Commercial |
$60.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.84
|
| Rate for Payer: Cash Price |
$54.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.70
|
| Rate for Payer: Medical Associates Commercial |
$50.70
|
| Rate for Payer: Midlands Choice Commercial |
$47.32
|
| Rate for Payer: United Healthcare Commercial |
$60.84
|
|
|
sodium phosphate 3 mmol/mL Sol [VDMC]
|
Facility
|
IP
|
$74.16
|
|
|
Service Code
|
NDC 00409-7391-72
|
| Hospital Charge Code |
28442909
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$51.91 |
| Max. Negotiated Rate |
$66.74 |
| Rate for Payer: Aetna of IA Commercial |
$66.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$66.74
|
| Rate for Payer: Cash Price |
$59.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$55.62
|
| Rate for Payer: Medical Associates Commercial |
$55.62
|
| Rate for Payer: Midlands Choice Commercial |
$51.91
|
| Rate for Payer: United Healthcare Commercial |
$66.74
|
|
|
sodium phosphate 3 mmol/mL Sol [VDMC]
|
Facility
|
OP
|
$74.16
|
|
|
Service Code
|
NDC 00409-7391-72
|
| Hospital Charge Code |
28442909
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.37 |
| Max. Negotiated Rate |
$66.74 |
| Rate for Payer: Aetna of IA Commercial |
$66.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$66.74
|
| Rate for Payer: Aetna of IA Medicare |
$42.27
|
| Rate for Payer: Amerigroup Medicaid |
$42.78
|
| Rate for Payer: Amerigroup Medicare |
$33.71
|
| Rate for Payer: Cash Price |
$59.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$55.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$33.37
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$42.36
|
| Rate for Payer: Medical Associates Commercial |
$55.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.37
|
| Rate for Payer: Midlands Choice Commercial |
$51.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$42.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$38.38
|
| Rate for Payer: United Healthcare Commercial |
$66.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$43.75
|
|
|
sodium phosphate-sodium biphosphate 18%-48% Oral Sol 45 mL [VDMC]
|
Facility
|
IP
|
$20.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421497
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.09 |
| Max. Negotiated Rate |
$18.11 |
| Rate for Payer: Aetna of IA Commercial |
$18.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.11
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.09
|
| Rate for Payer: Medical Associates Commercial |
$15.09
|
| Rate for Payer: Midlands Choice Commercial |
$14.09
|
| Rate for Payer: United Healthcare Commercial |
$18.11
|
|
|
sodium phosphate-sodium biphosphate 18%-48% Oral Sol 45 mL [VDMC]
|
Facility
|
OP
|
$20.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421497
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$18.11 |
| Rate for Payer: Aetna of IA Commercial |
$18.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.11
|
| Rate for Payer: Aetna of IA Medicare |
$11.47
|
| Rate for Payer: Amerigroup Medicaid |
$11.61
|
| Rate for Payer: Amerigroup Medicare |
$9.15
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.49
|
| Rate for Payer: Medical Associates Commercial |
$15.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.05
|
| Rate for Payer: Midlands Choice Commercial |
$14.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.41
|
| Rate for Payer: United Healthcare Commercial |
$18.11
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.87
|
|
|
sodium polystyrene sulfonate 15 g/60 mL Oral Susp [VDMC]
|
Facility
|
OP
|
$75.74
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421822
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.08 |
| Max. Negotiated Rate |
$68.17 |
| Rate for Payer: Aetna of IA Commercial |
$68.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.17
|
| Rate for Payer: Aetna of IA Medicare |
$43.17
|
| Rate for Payer: Amerigroup Medicaid |
$43.69
|
| Rate for Payer: Amerigroup Medicare |
$34.42
|
| Rate for Payer: Cash Price |
$60.59
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$56.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$34.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$43.26
|
| Rate for Payer: Medical Associates Commercial |
$56.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$34.08
|
| Rate for Payer: Midlands Choice Commercial |
$53.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$43.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.20
|
| Rate for Payer: United Healthcare Commercial |
$68.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$44.69
|
|
|
sodium polystyrene sulfonate 15 g/60 mL Oral Susp [VDMC]
|
Facility
|
IP
|
$75.74
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10421822
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$53.02 |
| Max. Negotiated Rate |
$68.17 |
| Rate for Payer: Aetna of IA Commercial |
$68.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.17
|
| Rate for Payer: Cash Price |
$60.59
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$56.80
|
| Rate for Payer: Medical Associates Commercial |
$56.80
|
| Rate for Payer: Midlands Choice Commercial |
$53.02
|
| Rate for Payer: United Healthcare Commercial |
$68.17
|
|
|
sodium thiosulfate 25% SDV Sol[VDMC]
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
HCPCS J0209
|
| Hospital Charge Code |
12817991
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$365.40 |
| Rate for Payer: Aetna of IA Commercial |
$365.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$365.40
|
| Rate for Payer: Aetna of IA Medicare |
$231.42
|
| Rate for Payer: Amerigroup Medicaid |
$234.18
|
| Rate for Payer: Amerigroup Medicare |
$184.53
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$304.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$182.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$231.91
|
| Rate for Payer: Medical Associates Commercial |
$304.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$182.70
|
| Rate for Payer: Midlands Choice Commercial |
$284.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$235.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$210.10
|
| Rate for Payer: United Healthcare Commercial |
$365.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$239.54
|
|
