|
buffered lidocaine/epi 1:100,000/8.4% 5ml Syringe[VDMC]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 99999-6625-02
|
| Hospital Charge Code |
15046134
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.00 |
| 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: Aetna of IA Medicare |
$22.80
|
| Rate for Payer: Amerigroup Medicaid |
$23.07
|
| Rate for Payer: Amerigroup Medicare |
$18.18
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.85
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.70
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
|
|
bumetanide 0.25 mg/mL 10ml MDV Inj Sol [VDMC]
|
Facility
|
OP
|
$26.55
|
|
|
Service Code
|
HCPCS J1939
|
| Hospital Charge Code |
10371107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.95 |
| Max. Negotiated Rate |
$23.90 |
| Rate for Payer: Aetna of IA Commercial |
$23.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.90
|
| Rate for Payer: Aetna of IA Medicare |
$15.13
|
| Rate for Payer: Amerigroup Medicaid |
$15.32
|
| Rate for Payer: Amerigroup Medicare |
$12.07
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.91
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.17
|
| Rate for Payer: Medical Associates Commercial |
$19.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.95
|
| Rate for Payer: Midlands Choice Commercial |
$18.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.74
|
| Rate for Payer: United Healthcare Commercial |
$23.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.67
|
|
|
bumetanide 0.25 mg/mL 10ml MDV Inj Sol [VDMC]
|
Facility
|
IP
|
$26.55
|
|
|
Service Code
|
HCPCS J1939
|
| Hospital Charge Code |
10371107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$23.90 |
| Rate for Payer: Aetna of IA Commercial |
$23.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.90
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.91
|
| Rate for Payer: Medical Associates Commercial |
$19.91
|
| Rate for Payer: Midlands Choice Commercial |
$18.59
|
| Rate for Payer: United Healthcare Commercial |
$23.90
|
|
|
bumetanide 1 mg Tab [VDMC]
|
Facility
|
IP
|
$3.58
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10371247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of IA Commercial |
$3.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.22
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.68
|
| Rate for Payer: Medical Associates Commercial |
$2.68
|
| Rate for Payer: Midlands Choice Commercial |
$2.50
|
| Rate for Payer: United Healthcare Commercial |
$3.22
|
|
|
bumetanide 1 mg Tab [VDMC]
|
Facility
|
OP
|
$3.58
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10371247
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of IA Commercial |
$3.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.22
|
| Rate for Payer: Aetna of IA Medicare |
$2.04
|
| Rate for Payer: Amerigroup Medicaid |
$2.06
|
| Rate for Payer: Amerigroup Medicare |
$1.63
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.04
|
| Rate for Payer: Medical Associates Commercial |
$2.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.61
|
| Rate for Payer: Midlands Choice Commercial |
$2.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.85
|
| Rate for Payer: United Healthcare Commercial |
$3.22
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.11
|
|
|
BUN
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
633605
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.00 |
| 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: Aetna of IA Medicare |
$22.80
|
| Rate for Payer: Amerigroup Medicaid |
$23.07
|
| Rate for Payer: Amerigroup Medicare |
$18.18
|
| Rate for Payer: Cash Price |
$32.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.85
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.70
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
|
|
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
|
IP
|
$2,592.00
|
|
|
Service Code
|
HCPCS 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
|
|
|
BUNION PLATE RIGHT
|
Facility
|
OP
|
$2,592.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8734818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,166.40 |
| 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: Aetna of IA Medicare |
$1,477.44
|
| Rate for Payer: Amerigroup Medicaid |
$1,495.07
|
| Rate for Payer: Amerigroup Medicare |
$1,178.06
|
| 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 |
$1,166.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,480.55
|
| Rate for Payer: Medical Associates Commercial |
$1,944.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,166.40
|
| Rate for Payer: Midlands Choice Commercial |
$1,814.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,502.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,341.36
|
| Rate for Payer: United Healthcare Commercial |
$2,332.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,529.28
|
|
|
bupivacaine 0.25% 10 ml SDV PF Inj Sol [VDMC]
|
Facility
|
IP
|
$24.60
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371316
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.22 |
| Max. Negotiated Rate |
$22.14 |
| Rate for Payer: Aetna of IA Commercial |
$22.14
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.14
|
| Rate for Payer: Cash Price |
$19.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.45
|
| Rate for Payer: Medical Associates Commercial |
$18.45
|
| Rate for Payer: Midlands Choice Commercial |
$17.22
|
| Rate for Payer: United Healthcare Commercial |
$22.14
|
|
|
bupivacaine 0.25% 10 ml SDV PF Inj Sol [VDMC]
|
Facility
|
OP
|
$24.60
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371316
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$22.14 |
| Rate for Payer: Aetna of IA Commercial |
$22.14
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.14
|
| Rate for Payer: Aetna of IA Medicare |
$14.02
|
| Rate for Payer: Amerigroup Medicaid |
$14.19
|
| Rate for Payer: Amerigroup Medicare |
$11.18
|
| Rate for Payer: Cash Price |
$19.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.45
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.07
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.05
|
| Rate for Payer: Medical Associates Commercial |
$18.45
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.07
|
| Rate for Payer: Midlands Choice Commercial |
$17.22
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.73
|
| Rate for Payer: United Healthcare Commercial |
$22.14
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.51
|
|
|
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 |
$9.00 |
| 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 |
$11.54
|
| Rate for Payer: Amerigroup Medicare |
$9.09
|
| 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 |
$9.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.42
|
| Rate for Payer: Medical Associates Commercial |
$15.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.00
|
| Rate for Payer: Midlands Choice Commercial |
$14.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.35
|
| Rate for Payer: United Healthcare Commercial |
$18.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.80
|
|
|
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 0.5% 10 ml SDV PF Inj Sol [VDMC]
|
Facility
|
IP
|
$29.68
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.77 |
| Max. Negotiated Rate |
$26.71 |
| Rate for Payer: Aetna of IA Commercial |
$26.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.71
|
| Rate for Payer: Cash Price |
$23.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.26
|
| Rate for Payer: Medical Associates Commercial |
$22.26
|
| Rate for Payer: Midlands Choice Commercial |
$20.77
|
| Rate for Payer: United Healthcare Commercial |
$26.71
|
|
|
bupivacaine 0.5% 10 ml SDV PF Inj Sol [VDMC]
|
Facility
|
OP
|
$29.68
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371458
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$26.71 |
| Rate for Payer: Aetna of IA Commercial |
$26.71
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.71
|
| Rate for Payer: Aetna of IA Medicare |
$16.92
|
| Rate for Payer: Amerigroup Medicaid |
$17.12
|
| Rate for Payer: Amerigroup Medicare |
$13.49
|
| Rate for Payer: Cash Price |
$23.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.26
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.95
|
| Rate for Payer: Medical Associates Commercial |
$22.26
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.35
|
| Rate for Payer: Midlands Choice Commercial |
$20.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.36
|
| Rate for Payer: United Healthcare Commercial |
$26.71
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.51
|
|
|
bupivacaine 0.5% PF SDV Inj Sol 30 mL [VDMC]
|
Facility
|
IP
|
$29.54
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371529
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$26.59 |
| Rate for Payer: Aetna of IA Commercial |
$26.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.59
|
| Rate for Payer: Cash Price |
$23.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.16
|
| Rate for Payer: Medical Associates Commercial |
$22.16
|
| Rate for Payer: Midlands Choice Commercial |
$20.68
|
| Rate for Payer: United Healthcare Commercial |
$26.59
|
|
|
bupivacaine 0.5% PF SDV Inj Sol 30 mL [VDMC]
|
Facility
|
OP
|
$29.54
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371529
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.29 |
| Max. Negotiated Rate |
$26.59 |
| Rate for Payer: Aetna of IA Commercial |
$26.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.59
|
| Rate for Payer: Aetna of IA Medicare |
$16.84
|
| Rate for Payer: Amerigroup Medicaid |
$17.04
|
| Rate for Payer: Amerigroup Medicare |
$13.43
|
| Rate for Payer: Cash Price |
$23.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.29
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.87
|
| Rate for Payer: Medical Associates Commercial |
$22.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.29
|
| Rate for Payer: Midlands Choice Commercial |
$20.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.29
|
| Rate for Payer: United Healthcare Commercial |
$26.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.43
|
|
|
bupivacaine 0.75% /Dextrose 8.25% Spinal SDV 2 mL [VDMC]
|
Facility
|
IP
|
$28.43
|
|
|
Service Code
|
HCPCS J0665
|
| 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% /Dextrose 8.25% Spinal SDV 2 mL [VDMC]
|
Facility
|
OP
|
$28.43
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371600
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.79 |
| 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 |
$16.20
|
| Rate for Payer: Amerigroup Medicaid |
$16.40
|
| Rate for Payer: Amerigroup Medicare |
$12.92
|
| 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 |
$12.79
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.24
|
| Rate for Payer: Medical Associates Commercial |
$21.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.79
|
| Rate for Payer: Midlands Choice Commercial |
$19.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.71
|
| Rate for Payer: United Healthcare Commercial |
$25.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.77
|
|
|
bupivacaine 0.75% PF SDV Inj Sol 10 mL [VDMC]
|
Facility
|
IP
|
$24.90
|
|
|
Service Code
|
HCPCS J0665
|
| 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 0.75% PF SDV Inj Sol 10 mL [VDMC]
|
Facility
|
OP
|
$24.90
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
10371671
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.21 |
| 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 |
$14.36
|
| Rate for Payer: Amerigroup Medicare |
$11.32
|
| 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 |
$11.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.22
|
| Rate for Payer: Medical Associates Commercial |
$18.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.21
|
| Rate for Payer: Midlands Choice Commercial |
$17.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.89
|
| Rate for Payer: United Healthcare Commercial |
$22.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.69
|
|
|
bupivacaine-epinephrine 0.5%-1:200,000- PF Inj 30 mL SDV [VDMC]
|
Facility
|
IP
|
$41.60
|
|
|
Service Code
|
HCPCS CN204
|
| Hospital Charge Code |
28796526
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$37.44 |
| Rate for Payer: Aetna of IA Commercial |
$37.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.44
|
| Rate for Payer: Cash Price |
$33.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.20
|
| Rate for Payer: Medical Associates Commercial |
$31.20
|
| Rate for Payer: Midlands Choice Commercial |
$29.12
|
| Rate for Payer: United Healthcare Commercial |
$37.44
|
|
|
bupivacaine-epinephrine 0.5%-1:200,000- PF Inj 30 mL SDV [VDMC]
|
Facility
|
OP
|
$41.60
|
|
|
Service Code
|
HCPCS CN204
|
| Hospital Charge Code |
28796526
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$37.44 |
| Rate for Payer: Aetna of IA Commercial |
$37.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.44
|
| Rate for Payer: Aetna of IA Medicare |
$23.71
|
| Rate for Payer: Amerigroup Medicaid |
$23.99
|
| Rate for Payer: Amerigroup Medicare |
$18.91
|
| Rate for Payer: Cash Price |
$33.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.76
|
| Rate for Payer: Medical Associates Commercial |
$31.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.72
|
| Rate for Payer: Midlands Choice Commercial |
$29.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.53
|
| Rate for Payer: United Healthcare Commercial |
$37.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.54
|
|
|
bupivacaine liposome 1.3% (13.3 mg/mL) Sus [VDMC]
|
Facility
|
IP
|
$1,524.47
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
10371742
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1,067.13 |
| Max. Negotiated Rate |
$1,372.02 |
| Rate for Payer: Aetna of IA Commercial |
$1,372.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,372.02
|
| Rate for Payer: Cash Price |
$1,219.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,143.35
|
| Rate for Payer: Medical Associates Commercial |
$1,143.35
|
| Rate for Payer: Midlands Choice Commercial |
$1,067.13
|
| Rate for Payer: United Healthcare Commercial |
$1,372.02
|
|
|
bupivacaine liposome 1.3% (13.3 mg/mL) Sus [VDMC]
|
Facility
|
OP
|
$1,524.47
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
10371742
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$686.01 |
| Max. Negotiated Rate |
$1,372.02 |
| Rate for Payer: Aetna of IA Commercial |
$1,372.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,372.02
|
| Rate for Payer: Aetna of IA Medicare |
$868.95
|
| Rate for Payer: Amerigroup Medicaid |
$879.31
|
| Rate for Payer: Amerigroup Medicare |
$692.87
|
| Rate for Payer: Cash Price |
$1,219.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,143.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$686.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$870.78
|
| Rate for Payer: Medical Associates Commercial |
$1,143.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$686.01
|
| Rate for Payer: Midlands Choice Commercial |
$1,067.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$883.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$788.91
|
| Rate for Payer: United Healthcare Commercial |
$1,372.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$899.44
|
|
