|
VRE CULTURE
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
4024793
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna of IA Commercial |
$50.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$50.40
|
| Rate for Payer: Aetna of IA Medicare |
$31.92
|
| Rate for Payer: Amerigroup Medicaid |
$32.30
|
| Rate for Payer: Amerigroup Medicare |
$25.45
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$25.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.99
|
| Rate for Payer: Medical Associates Commercial |
$42.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.20
|
| Rate for Payer: Midlands Choice Commercial |
$39.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$28.98
|
| Rate for Payer: United Healthcare Commercial |
$50.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.04
|
| Rate for Payer: Wellmark IA HMO WHPI |
$34.03
|
| Rate for Payer: Wellmark IA PPO |
$37.49
|
|
|
warfarin 1 mg Tab [VDMC]
|
Facility
|
OP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10432468
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.83
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.82
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.65
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
|
warfarin 1 mg Tab [VDMC]
|
Facility
|
IP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10432468
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
|
|
warfarin 2 mg Tab [VDMC]
|
Facility
|
IP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10428554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
|
|
warfarin 2 mg Tab [VDMC]
|
Facility
|
OP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10428554
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.83
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.82
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.65
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
|
warfarin 3 mg Tab [VDMC]
|
Facility
|
IP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10432533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
|
|
warfarin 3 mg Tab [VDMC]
|
Facility
|
OP
|
$1.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10432533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of IA Commercial |
$1.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.29
|
| Rate for Payer: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.83
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.82
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.65
|
| Rate for Payer: Midlands Choice Commercial |
$1.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
|
warfarin 5 mg Tab [VDMC]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10428621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna of IA Commercial |
$1.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.91
|
| Rate for Payer: Aetna of IA Medicare |
$1.21
|
| Rate for Payer: Amerigroup Medicaid |
$1.23
|
| Rate for Payer: Amerigroup Medicare |
$0.97
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.22
|
| Rate for Payer: Medical Associates Commercial |
$1.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.96
|
| Rate for Payer: Midlands Choice Commercial |
$1.49
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.91
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.26
|
|
|
warfarin 5 mg Tab [VDMC]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10428621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna of IA Commercial |
$1.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.91
|
| Rate for Payer: Cash Price |
$1.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.60
|
| Rate for Payer: Medical Associates Commercial |
$1.60
|
| Rate for Payer: Midlands Choice Commercial |
$1.49
|
| Rate for Payer: United Healthcare Commercial |
$1.91
|
|
|
WASHER 10MM TITANIUM 4.5NN SCREW
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna of IA Commercial |
$129.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$129.60
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$108.00
|
| Rate for Payer: Medical Associates Commercial |
$108.00
|
| Rate for Payer: Midlands Choice Commercial |
$100.80
|
| Rate for Payer: United Healthcare Commercial |
$129.60
|
|
|
WASHER 10MM TITANIUM 4.5NN SCREW
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$64.80 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna of IA Commercial |
$129.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$129.60
|
| Rate for Payer: Aetna of IA Medicare |
$82.08
|
| Rate for Payer: Amerigroup Medicaid |
$83.06
|
| Rate for Payer: Amerigroup Medicare |
$65.45
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$108.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$82.25
|
| Rate for Payer: Medical Associates Commercial |
$108.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.80
|
| Rate for Payer: Midlands Choice Commercial |
$100.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$83.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$74.52
|
| Rate for Payer: United Healthcare Commercial |
$129.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$84.96
|
|
|
WASHER 13MM TITANIUM 5.5MM SCREW
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047263
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
|
|
WASHER 13MM TITANIUM 5.5MM SCREW
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8047263
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Aetna of IA Medicare |
$59.28
|
| Rate for Payer: Amerigroup Medicaid |
$59.99
|
| Rate for Payer: Amerigroup Medicare |
$47.27
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$46.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.40
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$46.80
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$53.82
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.36
|
|
|
WASHER AXSOS SMALL FRAGMENT 9MM
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.10 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna of IA Commercial |
$34.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.20
|
| Rate for Payer: Aetna of IA Medicare |
$21.66
|
| Rate for Payer: Amerigroup Medicaid |
$21.92
|
| Rate for Payer: Amerigroup Medicare |
$17.27
|
| Rate for Payer: Cash Price |
$30.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.71
|
| Rate for Payer: Medical Associates Commercial |
$28.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.10
|
| Rate for Payer: Midlands Choice Commercial |
$26.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.66
|
| Rate for Payer: United Healthcare Commercial |
$34.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.42
|
|
|
WASHER AXSOS SMALL FRAGMENT 9MM
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8046701
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna of IA Commercial |
$34.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.20
|
| Rate for Payer: Cash Price |
$30.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.50
|
| Rate for Payer: Medical Associates Commercial |
$28.50
|
| Rate for Payer: Midlands Choice Commercial |
$26.60
|
| Rate for Payer: United Healthcare Commercial |
$34.20
|
|
|
WASHER FOR 4.5 SCREW
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8026401
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
|
|
WASHER FOR 4.5 SCREW
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8026401
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
water for irrigation sterile bottle SDV 500 mL [VDMC]
|
Facility
|
OP
|
$77.50
|
|
|
Service Code
|
NDC 00338-0004-03
|
| Hospital Charge Code |
10422585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.88 |
| Max. Negotiated Rate |
$69.75 |
| Rate for Payer: Aetna of IA Commercial |
$69.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.75
|
| Rate for Payer: Aetna of IA Medicare |
$44.18
|
| Rate for Payer: Amerigroup Medicaid |
$44.70
|
| Rate for Payer: Amerigroup Medicare |
$35.22
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$34.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$44.27
|
| Rate for Payer: Medical Associates Commercial |
$58.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$34.88
|
| Rate for Payer: Midlands Choice Commercial |
$54.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$44.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.11
|
| Rate for Payer: United Healthcare Commercial |
$69.75
|
| Rate for Payer: United Healthcare Managed Medicare |
$45.72
|
|
|
water for irrigation sterile bottle SDV 500 mL [VDMC]
|
Facility
|
IP
|
$77.50
|
|
|
Service Code
|
NDC 00338-0004-03
|
| Hospital Charge Code |
10422585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.25 |
| Max. Negotiated Rate |
$69.75 |
| Rate for Payer: Aetna of IA Commercial |
$69.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$69.75
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.12
|
| Rate for Payer: Medical Associates Commercial |
$58.12
|
| Rate for Payer: Midlands Choice Commercial |
$54.25
|
| Rate for Payer: United Healthcare Commercial |
$69.75
|
|
|
water for irrigation sterile bottle Sol 1000 mL [VDMC]
|
Facility
|
IP
|
$71.24
|
|
|
Service Code
|
NDC 00338-0004-04
|
| Hospital Charge Code |
10422443
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$49.87 |
| Max. Negotiated Rate |
$64.12 |
| Rate for Payer: Aetna of IA Commercial |
$64.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.12
|
| Rate for Payer: Cash Price |
$56.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.43
|
| Rate for Payer: Medical Associates Commercial |
$53.43
|
| Rate for Payer: Midlands Choice Commercial |
$49.87
|
| Rate for Payer: United Healthcare Commercial |
$64.12
|
|
|
water for irrigation sterile bottle Sol 1000 mL [VDMC]
|
Facility
|
OP
|
$71.24
|
|
|
Service Code
|
NDC 00338-0004-04
|
| Hospital Charge Code |
10422443
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.06 |
| Max. Negotiated Rate |
$64.12 |
| Rate for Payer: Aetna of IA Commercial |
$64.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$64.12
|
| Rate for Payer: Aetna of IA Medicare |
$40.61
|
| Rate for Payer: Amerigroup Medicaid |
$41.09
|
| Rate for Payer: Amerigroup Medicare |
$32.38
|
| Rate for Payer: Cash Price |
$56.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40.69
|
| Rate for Payer: Medical Associates Commercial |
$53.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.06
|
| Rate for Payer: Midlands Choice Commercial |
$49.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.29
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.87
|
| Rate for Payer: United Healthcare Commercial |
$64.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$42.03
|
|
|
water for irrigation sterile bottle Sol 250 mL [VDMC]
|
Facility
|
IP
|
$67.48
|
|
|
Service Code
|
NDC 00338-0004-02
|
| Hospital Charge Code |
10422514
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$47.24 |
| Max. Negotiated Rate |
$60.73 |
| Rate for Payer: Aetna of IA Commercial |
$60.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.73
|
| Rate for Payer: Cash Price |
$53.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.61
|
| Rate for Payer: Medical Associates Commercial |
$50.61
|
| Rate for Payer: Midlands Choice Commercial |
$47.24
|
| Rate for Payer: United Healthcare Commercial |
$60.73
|
|
|
water for irrigation sterile bottle Sol 250 mL [VDMC]
|
Facility
|
OP
|
$67.48
|
|
|
Service Code
|
NDC 00338-0004-02
|
| Hospital Charge Code |
10422514
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.37 |
| Max. Negotiated Rate |
$60.73 |
| Rate for Payer: Aetna of IA Commercial |
$60.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.73
|
| Rate for Payer: Aetna of IA Medicare |
$38.46
|
| Rate for Payer: Amerigroup Medicaid |
$38.92
|
| Rate for Payer: Amerigroup Medicare |
$30.67
|
| Rate for Payer: Cash Price |
$53.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.61
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.37
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.54
|
| Rate for Payer: Medical Associates Commercial |
$50.61
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.37
|
| Rate for Payer: Midlands Choice Commercial |
$47.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$39.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.92
|
| Rate for Payer: United Healthcare Commercial |
$60.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.81
|
|
|
WBC AND AUTO DIFF
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
CPT 85004
|
| Hospital Charge Code |
4006784
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$47.70 |
| Rate for Payer: Aetna of IA Commercial |
$47.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.70
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.75
|
| Rate for Payer: Medical Associates Commercial |
$39.75
|
| Rate for Payer: Midlands Choice Commercial |
$37.10
|
| Rate for Payer: United Healthcare Commercial |
$47.70
|
|
|
WBC AND AUTO DIFF
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
CPT 85004
|
| Hospital Charge Code |
4006784
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$23.85 |
| Max. Negotiated Rate |
$47.70 |
| Rate for Payer: Aetna of IA Commercial |
$47.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.70
|
| Rate for Payer: Aetna of IA Medicare |
$30.21
|
| Rate for Payer: Amerigroup Medicaid |
$30.57
|
| Rate for Payer: Amerigroup Medicare |
$24.09
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.27
|
| Rate for Payer: Medical Associates Commercial |
$39.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.85
|
| Rate for Payer: Midlands Choice Commercial |
$37.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$27.43
|
| Rate for Payer: United Healthcare Commercial |
$47.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.27
|
| Rate for Payer: Wellmark IA HMO WHPI |
$29.07
|
| Rate for Payer: Wellmark IA PPO |
$32.02
|
|
