|
BUN
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
633605
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of IA Commercial |
$36.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.00
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
|
|
BUNION PLATE RIGHT
|
Facility
|
OP
|
$2,592.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8734818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,295.48 |
| Max. Negotiated Rate |
$2,332.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,332.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,332.80
|
| Rate for Payer: Aetna of IA Medicare |
$1,477.44
|
| Rate for Payer: Amerigroup Medicaid |
$1,308.18
|
| Rate for Payer: Amerigroup Medicare |
$1,308.96
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,944.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,296.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,295.48
|
| Rate for Payer: Medical Associates Commercial |
$1,944.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,296.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,814.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,315.44
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1,314.66
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,944.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,944.00
|
| Rate for Payer: United Healthcare Commercial |
$2,332.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,529.28
|
|
|
BUNION PLATE RIGHT
|
Facility
|
IP
|
$2,592.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8734818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,814.40 |
| Max. Negotiated Rate |
$2,332.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,332.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,332.80
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,944.00
|
| Rate for Payer: Medical Associates Commercial |
$1,944.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,814.40
|
| Rate for Payer: United Healthcare Commercial |
$2,332.80
|
|
|
bupivacaine 0.25% 10 ml SDV PF Inj Sol [VDMC]
|
Facility
|
IP
|
$26.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371316
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$23.89 |
| Rate for Payer: Aetna of IA Commercial |
$23.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.89
|
| Rate for Payer: Cash Price |
$21.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.90
|
| Rate for Payer: Medical Associates Commercial |
$19.90
|
| Rate for Payer: Midlands Choice Commercial |
$18.58
|
| Rate for Payer: United Healthcare Commercial |
$23.89
|
|
|
bupivacaine 0.25% 10 ml SDV PF Inj Sol [VDMC]
|
Facility
|
OP
|
$26.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371316
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$23.89 |
| Rate for Payer: Aetna of IA Commercial |
$23.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.89
|
| Rate for Payer: Aetna of IA Medicare |
$15.13
|
| Rate for Payer: Amerigroup Medicaid |
$13.39
|
| Rate for Payer: Amerigroup Medicare |
$13.40
|
| Rate for Payer: Cash Price |
$21.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.26
|
| Rate for Payer: Medical Associates Commercial |
$19.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.27
|
| Rate for Payer: Midlands Choice Commercial |
$18.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.47
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$13.46
|
| Rate for Payer: Oscar Health of IA Commercial |
$19.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.90
|
| Rate for Payer: United Healthcare Commercial |
$23.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.66
|
|
|
bupivacaine 0.25% buffered lidocaine/epi 1:100,000/8.4%
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 99999-0167-01
|
| Hospital Charge Code |
15914149
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of IA Commercial |
$18.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.00
|
| Rate for Payer: Medical Associates Commercial |
$15.00
|
| Rate for Payer: Midlands Choice Commercial |
$14.00
|
| Rate for Payer: United Healthcare Commercial |
$18.00
|
|
|
bupivacaine 0.25% buffered lidocaine/epi 1:100,000/8.4%
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 99999-0167-01
|
| Hospital Charge Code |
15914149
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of IA Commercial |
$18.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$18.00
|
| Rate for Payer: Aetna of IA Medicare |
$11.40
|
| Rate for Payer: Amerigroup Medicaid |
$10.09
|
| Rate for Payer: Amerigroup Medicare |
$10.10
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$15.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.00
|
| Rate for Payer: Medical Associates Commercial |
$15.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.00
|
| Rate for Payer: Midlands Choice Commercial |
$14.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10.15
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$10.14
|
| Rate for Payer: Oscar Health of IA Commercial |
$15.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.00
|
| Rate for Payer: United Healthcare Commercial |
$18.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.80
|
|
|
bupivacaine 0.5% 10 ml SDV PF Inj Sol [VDMC]
|
Facility
|
IP
|
$24.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.88 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Aetna of IA Commercial |
$21.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.70
|
| Rate for Payer: Cash Price |
$19.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.08
|
| Rate for Payer: Medical Associates Commercial |
$18.08
|
| Rate for Payer: Midlands Choice Commercial |
$16.88
|
| Rate for Payer: United Healthcare Commercial |
$21.70
|
|
|
bupivacaine 0.5% 10 ml SDV PF Inj Sol [VDMC]
|
Facility
|
OP
|
$24.11
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Aetna of IA Commercial |
$21.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.70
|
| Rate for Payer: Aetna of IA Medicare |
$13.74
|
| Rate for Payer: Amerigroup Medicaid |
$12.17
|
| Rate for Payer: Amerigroup Medicare |
$12.18
|
| Rate for Payer: Cash Price |
$19.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.05
|
| Rate for Payer: Medical Associates Commercial |
$18.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.06
|
| Rate for Payer: Midlands Choice Commercial |
$16.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.24
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.23
|
| Rate for Payer: Oscar Health of IA Commercial |
$18.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.08
|
| Rate for Payer: United Healthcare Commercial |
$21.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.22
|
|
|
bupivacaine 0.5% PF SDV Inj Sol 30 mL [VDMC]
|
Facility
|
IP
|
$24.87
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371529
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.41 |
| Max. Negotiated Rate |
$22.38 |
| Rate for Payer: Aetna of IA Commercial |
$22.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.38
|
| Rate for Payer: Cash Price |
$19.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.65
|
| Rate for Payer: Medical Associates Commercial |
$18.65
|
| Rate for Payer: Midlands Choice Commercial |
$17.41
|
| Rate for Payer: United Healthcare Commercial |
$22.38
|
|
|
bupivacaine 0.5% PF SDV Inj Sol 30 mL [VDMC]
|
Facility
|
OP
|
$24.87
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371529
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$22.38 |
| Rate for Payer: Aetna of IA Commercial |
$22.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.38
|
| Rate for Payer: Aetna of IA Medicare |
$14.18
|
| Rate for Payer: Amerigroup Medicaid |
$12.55
|
| Rate for Payer: Amerigroup Medicare |
$12.56
|
| Rate for Payer: Cash Price |
$19.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.65
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.43
|
| Rate for Payer: Medical Associates Commercial |
$18.65
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.44
|
| Rate for Payer: Midlands Choice Commercial |
$17.41
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.62
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.61
|
| Rate for Payer: Oscar Health of IA Commercial |
$18.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.65
|
| Rate for Payer: United Healthcare Commercial |
$22.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.67
|
|
|
bupivacaine 0.75% /Dextrose 8.25% Spinal SDV 2 mL [VDMC]
|
Facility
|
OP
|
$28.43
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371600
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.21 |
| Max. Negotiated Rate |
$25.59 |
| Rate for Payer: Aetna of IA Commercial |
$25.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.59
|
| Rate for Payer: Aetna of IA Medicare |
$16.21
|
| Rate for Payer: Amerigroup Medicaid |
$14.35
|
| Rate for Payer: Amerigroup Medicare |
$14.36
|
| Rate for Payer: Cash Price |
$22.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.21
|
| Rate for Payer: Medical Associates Commercial |
$21.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.22
|
| Rate for Payer: Midlands Choice Commercial |
$19.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.43
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$14.42
|
| Rate for Payer: Oscar Health of IA Commercial |
$21.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.32
|
| Rate for Payer: United Healthcare Commercial |
$25.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.77
|
|
|
bupivacaine 0.75% /Dextrose 8.25% Spinal SDV 2 mL [VDMC]
|
Facility
|
IP
|
$28.43
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371600
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.90 |
| Max. Negotiated Rate |
$25.59 |
| Rate for Payer: Aetna of IA Commercial |
$25.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.59
|
| Rate for Payer: Cash Price |
$22.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.32
|
| Rate for Payer: Medical Associates Commercial |
$21.32
|
| Rate for Payer: Midlands Choice Commercial |
$19.90
|
| Rate for Payer: United Healthcare Commercial |
$25.59
|
|
|
bupivacaine 0.75% PF SDV Inj Sol 10 mL [VDMC]
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$22.41 |
| Rate for Payer: Aetna of IA Commercial |
$22.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.41
|
| Rate for Payer: Aetna of IA Medicare |
$14.19
|
| Rate for Payer: Amerigroup Medicaid |
$12.57
|
| Rate for Payer: Amerigroup Medicare |
$12.57
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.45
|
| Rate for Payer: Medical Associates Commercial |
$18.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.45
|
| Rate for Payer: Midlands Choice Commercial |
$17.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.64
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$12.63
|
| Rate for Payer: Oscar Health of IA Commercial |
$18.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.68
|
| Rate for Payer: United Healthcare Commercial |
$22.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.69
|
|
|
bupivacaine 0.75% PF SDV Inj Sol 10 mL [VDMC]
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$22.41 |
| Rate for Payer: Aetna of IA Commercial |
$22.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.41
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.68
|
| Rate for Payer: Medical Associates Commercial |
$18.68
|
| Rate for Payer: Midlands Choice Commercial |
$17.43
|
| Rate for Payer: United Healthcare Commercial |
$22.41
|
|
|
bupivacaine-EPINEPHrine 0.25%-1:200,000 SDV PF Inj Sol 30 mL [VDMC]
|
Facility
|
OP
|
$30.23
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.11 |
| Max. Negotiated Rate |
$27.21 |
| Rate for Payer: Aetna of IA Commercial |
$27.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.21
|
| Rate for Payer: Aetna of IA Medicare |
$17.23
|
| Rate for Payer: Amerigroup Medicaid |
$15.26
|
| Rate for Payer: Amerigroup Medicare |
$15.27
|
| Rate for Payer: Cash Price |
$24.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.67
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.11
|
| Rate for Payer: Medical Associates Commercial |
$22.67
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.12
|
| Rate for Payer: Midlands Choice Commercial |
$21.16
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.34
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$15.33
|
| Rate for Payer: Oscar Health of IA Commercial |
$22.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.67
|
| Rate for Payer: United Healthcare Commercial |
$27.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.84
|
|
|
bupivacaine-EPINEPHrine 0.25%-1:200,000 SDV PF Inj Sol 30 mL [VDMC]
|
Facility
|
IP
|
$30.23
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371880
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.16 |
| Max. Negotiated Rate |
$27.21 |
| Rate for Payer: Aetna of IA Commercial |
$27.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.21
|
| Rate for Payer: Cash Price |
$24.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.67
|
| Rate for Payer: Medical Associates Commercial |
$22.67
|
| Rate for Payer: Midlands Choice Commercial |
$21.16
|
| Rate for Payer: United Healthcare Commercial |
$27.21
|
|
|
bupivacaine-EPINEPHrine 0.5%-1:200,000 SDV PF Inj Sol 10 mL [VDMC]
|
Facility
|
OP
|
$33.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371947
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$30.46 |
| Rate for Payer: Aetna of IA Commercial |
$30.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.46
|
| Rate for Payer: Aetna of IA Medicare |
$19.29
|
| Rate for Payer: Amerigroup Medicaid |
$17.08
|
| Rate for Payer: Amerigroup Medicare |
$17.09
|
| Rate for Payer: Cash Price |
$27.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$16.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.91
|
| Rate for Payer: Medical Associates Commercial |
$25.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.92
|
| Rate for Payer: Midlands Choice Commercial |
$23.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.17
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$17.16
|
| Rate for Payer: Oscar Health of IA Commercial |
$25.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$25.38
|
| Rate for Payer: United Healthcare Commercial |
$30.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.97
|
|
|
bupivacaine-EPINEPHrine 0.5%-1:200,000 SDV PF Inj Sol 10 mL [VDMC]
|
Facility
|
IP
|
$33.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10371947
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.69 |
| Max. Negotiated Rate |
$30.46 |
| Rate for Payer: Aetna of IA Commercial |
$30.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.46
|
| Rate for Payer: Cash Price |
$27.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.38
|
| Rate for Payer: Medical Associates Commercial |
$25.38
|
| Rate for Payer: Midlands Choice Commercial |
$23.69
|
| Rate for Payer: United Healthcare Commercial |
$30.46
|
|
|
bupivacaine liposome 1.3% (13.3 mg/mL) Sus [VDMC]
|
Facility
|
OP
|
$1,480.65
|
|
|
Service Code
|
HCPCS C9290
|
| Hospital Charge Code |
10371742
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$740.03 |
| Max. Negotiated Rate |
$1,332.58 |
| Rate for Payer: Aetna of IA Commercial |
$1,332.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,332.58
|
| Rate for Payer: Aetna of IA Medicare |
$843.97
|
| Rate for Payer: Amerigroup Medicaid |
$747.28
|
| Rate for Payer: Amerigroup Medicare |
$747.73
|
| Rate for Payer: Cash Price |
$1,184.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,110.49
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$740.32
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$740.03
|
| Rate for Payer: Medical Associates Commercial |
$1,110.49
|
| Rate for Payer: Medical Associates Managed Medicare |
$740.32
|
| Rate for Payer: Midlands Choice Commercial |
$1,036.46
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$751.43
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$750.99
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,110.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,110.49
|
| Rate for Payer: United Healthcare Commercial |
$1,332.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$873.58
|
|
|
bupivacaine liposome 1.3% (13.3 mg/mL) Sus [VDMC]
|
Facility
|
IP
|
$1,480.65
|
|
|
Service Code
|
HCPCS C9290
|
| Hospital Charge Code |
10371742
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,036.46 |
| Max. Negotiated Rate |
$1,332.58 |
| Rate for Payer: Aetna of IA Commercial |
$1,332.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,332.58
|
| Rate for Payer: Cash Price |
$1,184.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,110.49
|
| Rate for Payer: Medical Associates Commercial |
$1,110.49
|
| Rate for Payer: Midlands Choice Commercial |
$1,036.46
|
| Rate for Payer: United Healthcare Commercial |
$1,332.58
|
|
|
buprenorphine 10mcg/hr Transdermal [VDMC]
|
Facility
|
OP
|
$180.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372211
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$90.40 |
| Max. Negotiated Rate |
$162.79 |
| Rate for Payer: Aetna of IA Commercial |
$162.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.79
|
| Rate for Payer: Aetna of IA Medicare |
$103.10
|
| Rate for Payer: Amerigroup Medicaid |
$91.29
|
| Rate for Payer: Amerigroup Medicare |
$91.34
|
| Rate for Payer: Cash Price |
$144.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$90.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$90.40
|
| Rate for Payer: Medical Associates Commercial |
$135.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.44
|
| Rate for Payer: Midlands Choice Commercial |
$126.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.80
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$91.74
|
| Rate for Payer: Oscar Health of IA Commercial |
$135.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$135.66
|
| Rate for Payer: United Healthcare Commercial |
$162.79
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.72
|
|
|
buprenorphine 10mcg/hr Transdermal [VDMC]
|
Facility
|
IP
|
$180.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10372211
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$126.62 |
| Max. Negotiated Rate |
$162.79 |
| Rate for Payer: Aetna of IA Commercial |
$162.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.79
|
| Rate for Payer: Cash Price |
$144.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.66
|
| Rate for Payer: Medical Associates Commercial |
$135.66
|
| Rate for Payer: Midlands Choice Commercial |
$126.62
|
| Rate for Payer: United Healthcare Commercial |
$162.79
|
|
|
buprenorphine 20 mcg/hr Fil [VDMC]
|
Facility
|
OP
|
$385.51
|
|
|
Service Code
|
NDC 59011-0752-04
|
| Hospital Charge Code |
10372081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$192.68 |
| Max. Negotiated Rate |
$346.96 |
| Rate for Payer: Aetna of IA Commercial |
$346.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$346.96
|
| Rate for Payer: Aetna of IA Medicare |
$219.74
|
| Rate for Payer: Amerigroup Medicaid |
$194.57
|
| Rate for Payer: Amerigroup Medicare |
$194.68
|
| Rate for Payer: Cash Price |
$308.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$289.13
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$192.76
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$192.68
|
| Rate for Payer: Medical Associates Commercial |
$289.13
|
| Rate for Payer: Medical Associates Managed Medicare |
$192.76
|
| Rate for Payer: Midlands Choice Commercial |
$269.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$195.65
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$195.53
|
| Rate for Payer: Oscar Health of IA Commercial |
$289.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$289.13
|
| Rate for Payer: United Healthcare Commercial |
$346.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$227.45
|
|
|
buprenorphine 20 mcg/hr Fil [VDMC]
|
Facility
|
IP
|
$385.51
|
|
|
Service Code
|
NDC 59011-0752-04
|
| Hospital Charge Code |
10372081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$269.86 |
| Max. Negotiated Rate |
$346.96 |
| Rate for Payer: Aetna of IA Commercial |
$346.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$346.96
|
| Rate for Payer: Cash Price |
$308.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$289.13
|
| Rate for Payer: Medical Associates Commercial |
$289.13
|
| Rate for Payer: Midlands Choice Commercial |
$269.86
|
| Rate for Payer: United Healthcare Commercial |
$346.96
|
|
