|
epoetin alfa 2000 units/mL PF SDV [VDMC]
|
Facility
IP
|
$148.03
|
|
|
Service Code
|
CPT J0885
|
| Hospital Charge Code |
43700210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.62 |
| Max. Negotiated Rate |
$133.23 |
| Rate for Payer: Aetna of IA Commercial |
$133.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.23
|
| Rate for Payer: Cash Price |
$118.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.02
|
| Rate for Payer: Medical Associates Commercial |
$111.02
|
| Rate for Payer: Midlands Choice Commercial |
$103.62
|
| Rate for Payer: United Healthcare Commercial |
$133.23
|
|
|
epoetin alfa 2000 units/mL PF SDV [VDMC]
|
Facility
OP
|
$148.03
|
|
|
Service Code
|
CPT J0885
|
| Hospital Charge Code |
43700210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$133.23 |
| Rate for Payer: Aetna of IA Commercial |
$133.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.23
|
| Rate for Payer: Aetna of IA Medicare |
$84.38
|
| Rate for Payer: Amerigroup Medicaid |
$74.71
|
| Rate for Payer: Amerigroup Medicare |
$74.76
|
| Rate for Payer: Cash Price |
$118.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$74.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.99
|
| Rate for Payer: Medical Associates Commercial |
$111.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$74.02
|
| Rate for Payer: Midlands Choice Commercial |
$103.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$75.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$111.02
|
| Rate for Payer: United Healthcare Commercial |
$133.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$87.34
|
|
|
epoetin alfa-epbx 10,000 units/mL 1ml SDV preservative-free Sol
|
Facility
IP
|
$373.35
|
|
|
Service Code
|
CPT Q5106
|
| Hospital Charge Code |
43799920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$261.34 |
| Max. Negotiated Rate |
$336.02 |
| Rate for Payer: Aetna of IA Commercial |
$336.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.02
|
| Rate for Payer: Cash Price |
$298.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.01
|
| Rate for Payer: Medical Associates Commercial |
$280.01
|
| Rate for Payer: Midlands Choice Commercial |
$261.34
|
| Rate for Payer: United Healthcare Commercial |
$336.02
|
|
|
epoetin alfa-epbx 10,000 units/mL 1ml SDV preservative-free Sol
|
Facility
OP
|
$373.35
|
|
|
Service Code
|
CPT Q5106
|
| Hospital Charge Code |
43799920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$186.60 |
| Max. Negotiated Rate |
$336.02 |
| Rate for Payer: Aetna of IA Commercial |
$336.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.02
|
| Rate for Payer: Aetna of IA Medicare |
$212.81
|
| Rate for Payer: Amerigroup Medicaid |
$188.43
|
| Rate for Payer: Amerigroup Medicare |
$188.54
|
| Rate for Payer: Cash Price |
$298.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$186.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$186.60
|
| Rate for Payer: Medical Associates Commercial |
$280.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$186.68
|
| Rate for Payer: Midlands Choice Commercial |
$261.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$189.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$280.01
|
| Rate for Payer: United Healthcare Commercial |
$336.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$220.28
|
|
|
Epstein Barr Virus Profile DMCL
|
Facility
OP
|
$114.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
8519173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$57.54
|
| Rate for Payer: Amerigroup Medicare |
$57.57
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.98
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.00
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
Epstein Barr Virus Profile DMCL
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
8519173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
ergocalciferol 50,000 intl units Cap
|
Facility
OP
|
$1.50
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of IA Commercial |
$1.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.35
|
| Rate for Payer: Aetna of IA Medicare |
$0.86
|
| Rate for Payer: Amerigroup Medicaid |
$0.76
|
| Rate for Payer: Amerigroup Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.75
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.75
|
| Rate for Payer: Midlands Choice Commercial |
$1.05
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.89
|
|
|
ergocalciferol 50,000 intl units Cap
|
Facility
IP
|
$1.50
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of IA Commercial |
$1.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.35
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
|
|
ertapenem 1 g Inj SDV
|
Facility
OP
|
$111.50
|
|
|
Service Code
|
CPT J1335
|
| Hospital Charge Code |
43722017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.73 |
| Max. Negotiated Rate |
$100.35 |
| Rate for Payer: Aetna of IA Commercial |
$100.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.35
|
| Rate for Payer: Aetna of IA Medicare |
$63.56
|
| Rate for Payer: Amerigroup Medicaid |
$56.27
|
| Rate for Payer: Amerigroup Medicare |
$56.31
|
| Rate for Payer: Cash Price |
$89.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.73
|
| Rate for Payer: Medical Associates Commercial |
$83.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.75
|
| Rate for Payer: Midlands Choice Commercial |
$78.05
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.62
|
| Rate for Payer: United Healthcare Commercial |
$100.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.78
|
|
|
ertapenem 1 g Inj SDV
|
Facility
IP
|
$111.50
|
|
|
Service Code
|
CPT J1335
|
| Hospital Charge Code |
43722017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.05 |
| Max. Negotiated Rate |
$100.35 |
| Rate for Payer: Aetna of IA Commercial |
$100.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.35
|
| Rate for Payer: Cash Price |
$89.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.62
|
| Rate for Payer: Medical Associates Commercial |
$83.62
|
| Rate for Payer: Midlands Choice Commercial |
$78.05
|
| Rate for Payer: United Healthcare Commercial |
$100.35
|
|
|
erythromycin ophthalmic 0.5% Oint. 3.5gm
|
Facility
IP
|
$49.80
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701076
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.86 |
| Max. Negotiated Rate |
$44.82 |
| Rate for Payer: Aetna of IA Commercial |
$44.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.82
|
| Rate for Payer: Cash Price |
$39.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.35
|
| Rate for Payer: Medical Associates Commercial |
$37.35
|
| Rate for Payer: Midlands Choice Commercial |
$34.86
|
| Rate for Payer: United Healthcare Commercial |
$44.82
|
|
|
erythromycin ophthalmic 0.5% Oint. 3.5gm
|
Facility
OP
|
$49.80
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701076
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$44.82 |
| Rate for Payer: Aetna of IA Commercial |
$44.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.82
|
| Rate for Payer: Aetna of IA Medicare |
$28.39
|
| Rate for Payer: Amerigroup Medicaid |
$25.13
|
| Rate for Payer: Amerigroup Medicare |
$25.15
|
| Rate for Payer: Cash Price |
$39.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.89
|
| Rate for Payer: Medical Associates Commercial |
$37.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.90
|
| Rate for Payer: Midlands Choice Commercial |
$34.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$37.35
|
| Rate for Payer: United Healthcare Commercial |
$44.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$29.38
|
|
|
Erythropoietin Level DMCL
|
Facility
IP
|
$179.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
8037840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
|
|
Erythropoietin Level DMCL
|
Facility
OP
|
$179.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
8037840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Aetna of IA Medicare |
$102.03
|
| Rate for Payer: Amerigroup Medicaid |
$90.34
|
| Rate for Payer: Amerigroup Medicare |
$90.40
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$89.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.46
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$89.50
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$90.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$134.25
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$105.61
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
escitalopram 10 mg Tab
|
Facility
OP
|
$1.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702689
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of IA Commercial |
$1.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.01
|
| Rate for Payer: Aetna of IA Medicare |
$0.64
|
| Rate for Payer: Amerigroup Medicaid |
$0.57
|
| Rate for Payer: Amerigroup Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.56
|
| Rate for Payer: Medical Associates Commercial |
$0.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.56
|
| Rate for Payer: Midlands Choice Commercial |
$0.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.01
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.66
|
|
|
escitalopram 10 mg Tab
|
Facility
IP
|
$1.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702689
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of IA Commercial |
$1.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.01
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.84
|
| Rate for Payer: Medical Associates Commercial |
$0.84
|
| Rate for Payer: Midlands Choice Commercial |
$0.78
|
| Rate for Payer: United Healthcare Commercial |
$1.01
|
|
|
esketamine 56 mg/2 Nasal Spray
|
Facility
OP
|
$2,938.16
|
|
|
Service Code
|
CPT S0013
|
| Hospital Charge Code |
43700359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,468.49 |
| Max. Negotiated Rate |
$2,644.34 |
| Rate for Payer: Aetna of IA Commercial |
$2,644.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,644.34
|
| Rate for Payer: Aetna of IA Medicare |
$1,674.75
|
| Rate for Payer: Amerigroup Medicaid |
$1,482.89
|
| Rate for Payer: Amerigroup Medicare |
$1,483.77
|
| Rate for Payer: Cash Price |
$2,350.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,203.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,469.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,468.49
|
| Rate for Payer: Medical Associates Commercial |
$2,203.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,469.08
|
| Rate for Payer: Midlands Choice Commercial |
$2,056.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,491.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,203.62
|
| Rate for Payer: United Healthcare Commercial |
$2,644.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,733.51
|
|
|
esketamine 56 mg/2 Nasal Spray
|
Facility
IP
|
$2,938.16
|
|
|
Service Code
|
CPT S0013
|
| Hospital Charge Code |
43700359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,056.71 |
| Max. Negotiated Rate |
$2,644.34 |
| Rate for Payer: Aetna of IA Commercial |
$2,644.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,644.34
|
| Rate for Payer: Cash Price |
$2,350.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,203.62
|
| Rate for Payer: Medical Associates Commercial |
$2,203.62
|
| Rate for Payer: Midlands Choice Commercial |
$2,056.71
|
| Rate for Payer: United Healthcare Commercial |
$2,644.34
|
|
|
esketamine 84 mg/3 nasal spray
|
Facility
IP
|
$4,405.76
|
|
|
Service Code
|
CPT S0013
|
| Hospital Charge Code |
43700390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,084.03 |
| Max. Negotiated Rate |
$3,965.18 |
| Rate for Payer: Aetna of IA Commercial |
$3,965.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,965.18
|
| Rate for Payer: Cash Price |
$3,524.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,304.32
|
| Rate for Payer: Medical Associates Commercial |
$3,304.32
|
| Rate for Payer: Midlands Choice Commercial |
$3,084.03
|
| Rate for Payer: United Healthcare Commercial |
$3,965.18
|
|
|
esketamine 84 mg/3 nasal spray
|
Facility
OP
|
$4,405.76
|
|
|
Service Code
|
CPT S0013
|
| Hospital Charge Code |
43700390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,202.00 |
| Max. Negotiated Rate |
$3,965.18 |
| Rate for Payer: Aetna of IA Commercial |
$3,965.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,965.18
|
| Rate for Payer: Aetna of IA Medicare |
$2,511.28
|
| Rate for Payer: Amerigroup Medicaid |
$2,223.59
|
| Rate for Payer: Amerigroup Medicare |
$2,224.91
|
| Rate for Payer: Cash Price |
$3,524.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,304.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,202.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,202.00
|
| Rate for Payer: Medical Associates Commercial |
$3,304.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,202.88
|
| Rate for Payer: Midlands Choice Commercial |
$3,084.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,235.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,304.32
|
| Rate for Payer: United Healthcare Commercial |
$3,965.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,599.40
|
|
|
esmolol 10 mg/mL 10 ml SDV Vial
|
Facility
IP
|
$27.14
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$24.43 |
| Rate for Payer: Aetna of IA Commercial |
$24.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.43
|
| Rate for Payer: Cash Price |
$21.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.36
|
| Rate for Payer: Medical Associates Commercial |
$20.36
|
| Rate for Payer: Midlands Choice Commercial |
$19.00
|
| Rate for Payer: United Healthcare Commercial |
$24.43
|
|
|
esmolol 10 mg/mL 10 ml SDV Vial
|
Facility
OP
|
$27.14
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.56 |
| Max. Negotiated Rate |
$24.43 |
| Rate for Payer: Aetna of IA Commercial |
$24.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.43
|
| Rate for Payer: Aetna of IA Medicare |
$15.47
|
| Rate for Payer: Amerigroup Medicaid |
$13.70
|
| Rate for Payer: Amerigroup Medicare |
$13.71
|
| Rate for Payer: Cash Price |
$21.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.56
|
| Rate for Payer: Medical Associates Commercial |
$20.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.57
|
| Rate for Payer: Midlands Choice Commercial |
$19.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.36
|
| Rate for Payer: United Healthcare Commercial |
$24.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.01
|
|
|
Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders With MCC
|
Facility
IP
|
$10,181.98
|
|
|
Service Code
|
MS-DRG 391
|
| Hospital Charge Code |
232
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$10,181.98 |
| Rate for Payer: Amerigroup Medicaid |
$10,132.79
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10,034.41
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,181.98
|
|
|
Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders Without MCC
|
Facility
IP
|
$6,283.40
|
|
|
Service Code
|
MS-DRG 392
|
| Hospital Charge Code |
233
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$6,283.40 |
| Rate for Payer: Amerigroup Medicaid |
$6,253.05
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,192.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,283.40
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
|
Facility
OP
|
$2,263.56
|
|
|
Service Code
|
CPT 43235
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,057.78 |
| Max. Negotiated Rate |
$2,263.56 |
| Rate for Payer: Wellmark IA HMO |
$2,057.78
|
| Rate for Payer: Wellmark IA PPO |
$2,263.56
|
|
