|
dorzolamide-timolol Ophth 22.3mg-6.8mg Sol
|
Facility
OP
|
$55.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.55 |
| Max. Negotiated Rate |
$49.61 |
| Rate for Payer: Aetna of IA Commercial |
$49.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.61
|
| Rate for Payer: Aetna of IA Medicare |
$31.42
|
| Rate for Payer: Amerigroup Medicaid |
$27.82
|
| Rate for Payer: Amerigroup Medicare |
$27.84
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27.55
|
| Rate for Payer: Medical Associates Commercial |
$41.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.56
|
| Rate for Payer: Midlands Choice Commercial |
$38.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$41.34
|
| Rate for Payer: United Healthcare Commercial |
$49.61
|
| Rate for Payer: United Healthcare Managed Medicare |
$32.52
|
|
|
dorzolamide-timolol Ophth 22.3mg-6.8mg Sol
|
Facility
IP
|
$55.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$49.61 |
| Rate for Payer: Aetna of IA Commercial |
$49.61
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.61
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.34
|
| Rate for Payer: Medical Associates Commercial |
$41.34
|
| Rate for Payer: Midlands Choice Commercial |
$38.58
|
| Rate for Payer: United Healthcare Commercial |
$49.61
|
|
|
DOT Urine Drug Collection
|
Facility
IP
|
$40.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
4022798
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
DOT Urine Drug Collection
|
Facility
OP
|
$40.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
4022798
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.99 |
| 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 |
$20.19
|
| Rate for Payer: Amerigroup Medicare |
$20.20
|
| 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 |
$20.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.99
|
| Rate for Payer: Medical Associates Commercial |
$30.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.00
|
| Rate for Payer: Midlands Choice Commercial |
$28.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$36.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.60
|
|
|
DOUBLE ENDED K-WIRE 0.062
|
Facility
OP
|
$17.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
8852331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of IA Commercial |
$15.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.30
|
| Rate for Payer: Aetna of IA Medicare |
$9.69
|
| Rate for Payer: Amerigroup Medicaid |
$8.58
|
| Rate for Payer: Amerigroup Medicare |
$8.58
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.50
|
| Rate for Payer: Medical Associates Commercial |
$12.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.50
|
| Rate for Payer: Midlands Choice Commercial |
$11.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.75
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.03
|
|
|
DOUBLE ENDED K-WIRE 0.062
|
Facility
IP
|
$17.00
|
|
|
Service Code
|
CPT C1769
|
| Hospital Charge Code |
8852331
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of IA Commercial |
$15.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.30
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.75
|
| Rate for Payer: Medical Associates Commercial |
$12.75
|
| Rate for Payer: Midlands Choice Commercial |
$11.90
|
| Rate for Payer: United Healthcare Commercial |
$15.30
|
|
|
doxapram 20 mg/mL 20ml MDV
|
Facility
OP
|
$198.77
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701292
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.35 |
| Max. Negotiated Rate |
$178.89 |
| Rate for Payer: Aetna of IA Commercial |
$178.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.89
|
| Rate for Payer: Aetna of IA Medicare |
$113.30
|
| Rate for Payer: Amerigroup Medicaid |
$100.32
|
| Rate for Payer: Amerigroup Medicare |
$100.38
|
| Rate for Payer: Cash Price |
$159.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$149.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$99.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$99.35
|
| Rate for Payer: Medical Associates Commercial |
$149.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$99.38
|
| Rate for Payer: Midlands Choice Commercial |
$139.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$100.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$149.08
|
| Rate for Payer: United Healthcare Commercial |
$178.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$117.27
|
|
|
doxapram 20 mg/mL 20ml MDV
|
Facility
IP
|
$198.77
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701292
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$139.14 |
| Max. Negotiated Rate |
$178.89 |
| Rate for Payer: Aetna of IA Commercial |
$178.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.89
|
| Rate for Payer: Cash Price |
$159.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$149.08
|
| Rate for Payer: Medical Associates Commercial |
$149.08
|
| Rate for Payer: Midlands Choice Commercial |
$139.14
|
| Rate for Payer: United Healthcare Commercial |
$178.89
|
|
|
doxazosin 2 mg Tab
|
Facility
OP
|
$1.30
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of IA Commercial |
$1.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.17
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.66
|
| Rate for Payer: Amerigroup Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| 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 |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.65
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
doxazosin 2 mg Tab
|
Facility
IP
|
$1.30
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of IA Commercial |
$1.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.17
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
|
|
doxepin 10 mg Cap
|
Facility
IP
|
$1.15
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702068
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of IA Commercial |
$1.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.04
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.86
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Midlands Choice Commercial |
$0.81
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
|
|
doxepin 10 mg Cap
|
Facility
OP
|
$1.15
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702068
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of IA Commercial |
$1.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.04
|
| Rate for Payer: Aetna of IA Medicare |
$0.66
|
| Rate for Payer: Amerigroup Medicaid |
$0.58
|
| Rate for Payer: Amerigroup Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.57
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.68
|
|
|
doxepin 25 mg Cap
|
Facility
IP
|
$1.21
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of IA Commercial |
$1.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.09
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.91
|
| Rate for Payer: Medical Associates Commercial |
$0.91
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
|
|
doxepin 25 mg Cap
|
Facility
OP
|
$1.21
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of IA Commercial |
$1.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.09
|
| Rate for Payer: Aetna of IA Medicare |
$0.69
|
| Rate for Payer: Amerigroup Medicaid |
$0.61
|
| Rate for Payer: Amerigroup Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.91
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.60
|
| Rate for Payer: Medical Associates Commercial |
$0.91
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.61
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$1.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.71
|
|
|
DOXOrubicin 2 mg/mL 100 ml MDV
|
Facility
OP
|
$568.52
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
43706691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$284.15 |
| Max. Negotiated Rate |
$511.67 |
| Rate for Payer: Aetna of IA Commercial |
$511.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$511.67
|
| Rate for Payer: Aetna of IA Medicare |
$324.06
|
| Rate for Payer: Amerigroup Medicaid |
$286.93
|
| Rate for Payer: Amerigroup Medicare |
$287.10
|
| Rate for Payer: Cash Price |
$454.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$426.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$284.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$284.15
|
| Rate for Payer: Medical Associates Commercial |
$426.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$284.26
|
| Rate for Payer: Midlands Choice Commercial |
$397.96
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$288.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$426.39
|
| Rate for Payer: United Healthcare Commercial |
$511.67
|
| Rate for Payer: United Healthcare Managed Medicare |
$335.43
|
|
|
DOXOrubicin 2 mg/mL 100 ml MDV
|
Facility
IP
|
$568.52
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
43706691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$397.96 |
| Max. Negotiated Rate |
$511.67 |
| Rate for Payer: Aetna of IA Commercial |
$511.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$511.67
|
| Rate for Payer: Cash Price |
$454.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$426.39
|
| Rate for Payer: Medical Associates Commercial |
$426.39
|
| Rate for Payer: Midlands Choice Commercial |
$397.96
|
| Rate for Payer: United Healthcare Commercial |
$511.67
|
|
|
DOXOrubicin 2 mg/mL10ml SDV
|
Facility
OP
|
$109.08
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
43701079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.52 |
| Max. Negotiated Rate |
$98.17 |
| Rate for Payer: Aetna of IA Commercial |
$98.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.17
|
| Rate for Payer: Aetna of IA Medicare |
$62.18
|
| Rate for Payer: Amerigroup Medicaid |
$55.05
|
| Rate for Payer: Amerigroup Medicare |
$55.09
|
| Rate for Payer: Cash Price |
$87.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.81
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$54.52
|
| Rate for Payer: Medical Associates Commercial |
$81.81
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.54
|
| Rate for Payer: Midlands Choice Commercial |
$76.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$55.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.81
|
| Rate for Payer: United Healthcare Commercial |
$98.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.36
|
|
|
DOXOrubicin 2 mg/mL10ml SDV
|
Facility
IP
|
$109.08
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
43701079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.36 |
| Max. Negotiated Rate |
$98.17 |
| Rate for Payer: Aetna of IA Commercial |
$98.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$98.17
|
| Rate for Payer: Cash Price |
$87.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.81
|
| Rate for Payer: Medical Associates Commercial |
$81.81
|
| Rate for Payer: Midlands Choice Commercial |
$76.36
|
| Rate for Payer: United Healthcare Commercial |
$98.17
|
|
|
DOXOrubicin 2 mg/mL 25 ml SDV
|
Facility
OP
|
$102.96
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
43706697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.46 |
| Max. Negotiated Rate |
$92.66 |
| Rate for Payer: Aetna of IA Commercial |
$92.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$92.66
|
| Rate for Payer: Aetna of IA Medicare |
$58.69
|
| Rate for Payer: Amerigroup Medicaid |
$51.96
|
| Rate for Payer: Amerigroup Medicare |
$51.99
|
| Rate for Payer: Cash Price |
$82.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$77.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$51.46
|
| Rate for Payer: Medical Associates Commercial |
$77.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.48
|
| Rate for Payer: Midlands Choice Commercial |
$72.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$52.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$77.22
|
| Rate for Payer: United Healthcare Commercial |
$92.66
|
| Rate for Payer: United Healthcare Managed Medicare |
$60.75
|
|
|
DOXOrubicin 2 mg/mL 25 ml SDV
|
Facility
IP
|
$102.96
|
|
|
Service Code
|
CPT J9000
|
| Hospital Charge Code |
43706697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.07 |
| Max. Negotiated Rate |
$92.66 |
| Rate for Payer: Aetna of IA Commercial |
$92.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$92.66
|
| Rate for Payer: Cash Price |
$82.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$77.22
|
| Rate for Payer: Medical Associates Commercial |
$77.22
|
| Rate for Payer: Midlands Choice Commercial |
$72.07
|
| Rate for Payer: United Healthcare Commercial |
$92.66
|
|
|
DOXOrubicin liposomal 2 mg/mL 10 ml SDV
|
Facility
OP
|
$2,646.40
|
|
|
Service Code
|
CPT Q2050
|
| Hospital Charge Code |
43700214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,322.67 |
| Max. Negotiated Rate |
$2,381.76 |
| Rate for Payer: Aetna of IA Commercial |
$2,381.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,381.76
|
| Rate for Payer: Aetna of IA Medicare |
$1,508.45
|
| Rate for Payer: Amerigroup Medicaid |
$1,335.64
|
| Rate for Payer: Amerigroup Medicare |
$1,336.43
|
| Rate for Payer: Cash Price |
$2,117.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,984.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,323.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,322.67
|
| Rate for Payer: Medical Associates Commercial |
$1,984.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,323.20
|
| Rate for Payer: Midlands Choice Commercial |
$1,852.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,343.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,984.80
|
| Rate for Payer: United Healthcare Commercial |
$2,381.76
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,561.38
|
|
|
DOXOrubicin liposomal 2 mg/mL 10 ml SDV
|
Facility
IP
|
$2,646.40
|
|
|
Service Code
|
CPT Q2050
|
| Hospital Charge Code |
43700214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,852.48 |
| Max. Negotiated Rate |
$2,381.76 |
| Rate for Payer: Aetna of IA Commercial |
$2,381.76
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,381.76
|
| Rate for Payer: Cash Price |
$2,117.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,984.80
|
| Rate for Payer: Medical Associates Commercial |
$1,984.80
|
| Rate for Payer: Midlands Choice Commercial |
$1,852.48
|
| Rate for Payer: United Healthcare Commercial |
$2,381.76
|
|
|
DOXOrubicin liposomal 2 mg/mL DSP 25ml SDV vial
|
Facility
OP
|
$6,541.04
|
|
|
Service Code
|
CPT Q2050
|
| Hospital Charge Code |
43700183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,269.21 |
| Max. Negotiated Rate |
$5,886.94 |
| Rate for Payer: Aetna of IA Commercial |
$5,886.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,886.94
|
| Rate for Payer: Aetna of IA Medicare |
$3,728.39
|
| Rate for Payer: Amerigroup Medicaid |
$3,301.26
|
| Rate for Payer: Amerigroup Medicare |
$3,303.23
|
| Rate for Payer: Cash Price |
$5,232.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,905.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,270.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,269.21
|
| Rate for Payer: Medical Associates Commercial |
$4,905.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,270.52
|
| Rate for Payer: Midlands Choice Commercial |
$4,578.73
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,319.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,905.78
|
| Rate for Payer: United Healthcare Commercial |
$5,886.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,859.21
|
|
|
DOXOrubicin liposomal 2 mg/mL DSP 25ml SDV vial
|
Facility
IP
|
$6,541.04
|
|
|
Service Code
|
CPT Q2050
|
| Hospital Charge Code |
43700183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,578.73 |
| Max. Negotiated Rate |
$5,886.94 |
| Rate for Payer: Aetna of IA Commercial |
$5,886.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,886.94
|
| Rate for Payer: Cash Price |
$5,232.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,905.78
|
| Rate for Payer: Medical Associates Commercial |
$4,905.78
|
| Rate for Payer: Midlands Choice Commercial |
$4,578.73
|
| Rate for Payer: United Healthcare Commercial |
$5,886.94
|
|
|
doxycycline 100 mg SDV Inj
|
Facility
IP
|
$66.97
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$60.27 |
| Rate for Payer: Aetna of IA Commercial |
$60.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.27
|
| Rate for Payer: Cash Price |
$53.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.23
|
| Rate for Payer: Medical Associates Commercial |
$50.23
|
| Rate for Payer: Midlands Choice Commercial |
$46.88
|
| Rate for Payer: United Healthcare Commercial |
$60.27
|
|
