|
Keppra Level DMCL
|
Facility
OP
|
$148.00
|
|
|
Service Code
|
CPT 80177
|
| Hospital Charge Code |
8037721
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Aetna of IA Medicare |
$84.36
|
| Rate for Payer: Amerigroup Medicaid |
$74.70
|
| Rate for Payer: Amerigroup Medicare |
$74.74
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$74.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.97
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$74.00
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$75.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$111.00
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$87.32
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
Keppra Level DMCL
|
Facility
IP
|
$148.00
|
|
|
Service Code
|
CPT 80177
|
| Hospital Charge Code |
8037721
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
|
|
ketamine 100 mg/mL 10 ml MDV Inj Sol
|
Facility
OP
|
$62.91
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43799930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.44 |
| Max. Negotiated Rate |
$56.62 |
| Rate for Payer: Aetna of IA Commercial |
$56.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.62
|
| Rate for Payer: Aetna of IA Medicare |
$35.86
|
| Rate for Payer: Amerigroup Medicaid |
$31.75
|
| Rate for Payer: Amerigroup Medicare |
$31.77
|
| Rate for Payer: Cash Price |
$50.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.44
|
| Rate for Payer: Medical Associates Commercial |
$47.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.46
|
| Rate for Payer: Midlands Choice Commercial |
$44.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.18
|
| Rate for Payer: United Healthcare Commercial |
$56.62
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.12
|
|
|
ketamine 100 mg/mL 10 ml MDV Inj Sol
|
Facility
IP
|
$62.91
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43799930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.04 |
| Max. Negotiated Rate |
$56.62 |
| Rate for Payer: Aetna of IA Commercial |
$56.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.62
|
| Rate for Payer: Cash Price |
$50.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.18
|
| Rate for Payer: Medical Associates Commercial |
$47.18
|
| Rate for Payer: Midlands Choice Commercial |
$44.04
|
| Rate for Payer: United Healthcare Commercial |
$56.62
|
|
|
ketamine 100 mg/mL 5 ml inj Sol
|
Facility
OP
|
$86.88
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$78.19 |
| Rate for Payer: Aetna of IA Commercial |
$78.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$78.19
|
| Rate for Payer: Aetna of IA Medicare |
$49.52
|
| Rate for Payer: Amerigroup Medicaid |
$43.85
|
| Rate for Payer: Amerigroup Medicare |
$43.87
|
| Rate for Payer: Cash Price |
$69.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$43.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$43.42
|
| Rate for Payer: Medical Associates Commercial |
$65.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$43.44
|
| Rate for Payer: Midlands Choice Commercial |
$60.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$44.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$65.16
|
| Rate for Payer: United Healthcare Commercial |
$78.19
|
| Rate for Payer: United Healthcare Managed Medicare |
$51.26
|
|
|
ketamine 100 mg/mL 5 ml inj Sol
|
Facility
IP
|
$86.88
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.82 |
| Max. Negotiated Rate |
$78.19 |
| Rate for Payer: Aetna of IA Commercial |
$78.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$78.19
|
| Rate for Payer: Cash Price |
$69.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.16
|
| Rate for Payer: Medical Associates Commercial |
$65.16
|
| Rate for Payer: Midlands Choice Commercial |
$60.82
|
| Rate for Payer: United Healthcare Commercial |
$78.19
|
|
|
ketamine 10 mg/mL 20 ml MDV Inj Sol
|
Facility
OP
|
$111.02
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43799931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.49 |
| Max. Negotiated Rate |
$99.92 |
| Rate for Payer: Aetna of IA Commercial |
$99.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.92
|
| Rate for Payer: Aetna of IA Medicare |
$63.28
|
| Rate for Payer: Amerigroup Medicaid |
$56.03
|
| Rate for Payer: Amerigroup Medicare |
$56.07
|
| Rate for Payer: Cash Price |
$88.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.26
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.49
|
| Rate for Payer: Medical Associates Commercial |
$83.26
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.51
|
| Rate for Payer: Midlands Choice Commercial |
$77.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.26
|
| Rate for Payer: United Healthcare Commercial |
$99.92
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.50
|
|
|
ketamine 10 mg/mL 20 ml MDV Inj Sol
|
Facility
IP
|
$111.02
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43799931
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.71 |
| Max. Negotiated Rate |
$99.92 |
| Rate for Payer: Aetna of IA Commercial |
$99.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.92
|
| Rate for Payer: Cash Price |
$88.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.26
|
| Rate for Payer: Medical Associates Commercial |
$83.26
|
| Rate for Payer: Midlands Choice Commercial |
$77.71
|
| Rate for Payer: United Healthcare Commercial |
$99.92
|
|
|
ketamine 50 mg/mL 10 ml MDV Inj Sol
|
Facility
IP
|
$48.12
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43712891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.68 |
| Max. Negotiated Rate |
$43.31 |
| Rate for Payer: Aetna of IA Commercial |
$43.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.31
|
| Rate for Payer: Cash Price |
$38.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.09
|
| Rate for Payer: Medical Associates Commercial |
$36.09
|
| Rate for Payer: Midlands Choice Commercial |
$33.68
|
| Rate for Payer: United Healthcare Commercial |
$43.31
|
|
|
ketamine 50 mg/mL 10 ml MDV Inj Sol
|
Facility
OP
|
$48.12
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43712891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$43.31 |
| Rate for Payer: Aetna of IA Commercial |
$43.31
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.31
|
| Rate for Payer: Aetna of IA Medicare |
$27.43
|
| Rate for Payer: Amerigroup Medicaid |
$24.29
|
| Rate for Payer: Amerigroup Medicare |
$24.30
|
| Rate for Payer: Cash Price |
$38.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.05
|
| Rate for Payer: Medical Associates Commercial |
$36.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.06
|
| Rate for Payer: Midlands Choice Commercial |
$33.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.09
|
| Rate for Payer: United Healthcare Commercial |
$43.31
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.39
|
|
|
ketoconazole 200 mg Tab
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43766128
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Aetna of IA Commercial |
$3.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.60
|
| Rate for Payer: Aetna of IA Medicare |
$2.28
|
| Rate for Payer: Amerigroup Medicaid |
$2.02
|
| Rate for Payer: Amerigroup Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.00
|
| Rate for Payer: Medical Associates Commercial |
$3.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.00
|
| Rate for Payer: Midlands Choice Commercial |
$2.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$3.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.36
|
|
|
ketoconazole 200 mg Tab
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43766128
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Aetna of IA Commercial |
$3.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.60
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.00
|
| Rate for Payer: Medical Associates Commercial |
$3.00
|
| Rate for Payer: Midlands Choice Commercial |
$2.80
|
| Rate for Payer: United Healthcare Commercial |
$3.60
|
|
|
ketoconazole Top 2% Crm 15gm
|
Facility
OP
|
$57.32
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.65 |
| Max. Negotiated Rate |
$51.59 |
| Rate for Payer: Aetna of IA Commercial |
$51.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.59
|
| Rate for Payer: Aetna of IA Medicare |
$32.67
|
| Rate for Payer: Amerigroup Medicaid |
$28.93
|
| Rate for Payer: Amerigroup Medicare |
$28.95
|
| Rate for Payer: Cash Price |
$45.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.99
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.65
|
| Rate for Payer: Medical Associates Commercial |
$42.99
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.66
|
| Rate for Payer: Midlands Choice Commercial |
$40.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.99
|
| Rate for Payer: United Healthcare Commercial |
$51.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.82
|
|
|
ketoconazole Top 2% Crm 15gm
|
Facility
IP
|
$57.32
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.12 |
| Max. Negotiated Rate |
$51.59 |
| Rate for Payer: Aetna of IA Commercial |
$51.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.59
|
| Rate for Payer: Cash Price |
$45.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.99
|
| Rate for Payer: Medical Associates Commercial |
$42.99
|
| Rate for Payer: Midlands Choice Commercial |
$40.12
|
| Rate for Payer: United Healthcare Commercial |
$51.59
|
|
|
ketoconazole topical 2% Shampoo 120 ml
|
Facility
OP
|
$62.76
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700503
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.37 |
| Max. Negotiated Rate |
$56.48 |
| Rate for Payer: Aetna of IA Commercial |
$56.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.48
|
| Rate for Payer: Aetna of IA Medicare |
$35.77
|
| Rate for Payer: Amerigroup Medicaid |
$31.67
|
| Rate for Payer: Amerigroup Medicare |
$31.69
|
| Rate for Payer: Cash Price |
$50.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.37
|
| Rate for Payer: Medical Associates Commercial |
$47.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.38
|
| Rate for Payer: Midlands Choice Commercial |
$43.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.07
|
| Rate for Payer: United Healthcare Commercial |
$56.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.03
|
|
|
ketoconazole topical 2% Shampoo 120 ml
|
Facility
IP
|
$62.76
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700503
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.93 |
| Max. Negotiated Rate |
$56.48 |
| Rate for Payer: Aetna of IA Commercial |
$56.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.48
|
| Rate for Payer: Cash Price |
$50.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.07
|
| Rate for Payer: Medical Associates Commercial |
$47.07
|
| Rate for Payer: Midlands Choice Commercial |
$43.93
|
| Rate for Payer: United Healthcare Commercial |
$56.48
|
|
|
KETONES SERUM
|
Facility
OP
|
$61.00
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
4022840
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Aetna of IA Medicare |
$34.77
|
| Rate for Payer: Amerigroup Medicaid |
$30.79
|
| Rate for Payer: Amerigroup Medicare |
$30.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.49
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.50
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.75
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.99
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
KETONES SERUM
|
Facility
IP
|
$61.00
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
4022840
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
|
|
ketorolac 10 mg Tab
|
Facility
OP
|
$3.96
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43731288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna of IA Commercial |
$3.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.56
|
| Rate for Payer: Aetna of IA Medicare |
$2.26
|
| Rate for Payer: Amerigroup Medicaid |
$2.00
|
| Rate for Payer: Amerigroup Medicare |
$2.00
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.98
|
| Rate for Payer: Medical Associates Commercial |
$2.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.98
|
| Rate for Payer: Midlands Choice Commercial |
$2.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.97
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.34
|
|
|
ketorolac 10 mg Tab
|
Facility
IP
|
$3.96
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43731288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna of IA Commercial |
$3.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.56
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.97
|
| Rate for Payer: Medical Associates Commercial |
$2.97
|
| Rate for Payer: Midlands Choice Commercial |
$2.77
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
|
|
ketorolac 15 mg/mL 1ml Inj SDV
|
Facility
IP
|
$22.83
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
43736600
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.98 |
| Max. Negotiated Rate |
$20.55 |
| Rate for Payer: Aetna of IA Commercial |
$20.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.55
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.12
|
| Rate for Payer: Medical Associates Commercial |
$17.12
|
| Rate for Payer: Midlands Choice Commercial |
$15.98
|
| Rate for Payer: United Healthcare Commercial |
$20.55
|
|
|
ketorolac 15 mg/mL 1ml Inj SDV
|
Facility
OP
|
$22.83
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
43736600
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$20.55 |
| Rate for Payer: Aetna of IA Commercial |
$20.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.55
|
| Rate for Payer: Aetna of IA Medicare |
$13.01
|
| Rate for Payer: Amerigroup Medicaid |
$11.52
|
| Rate for Payer: Amerigroup Medicare |
$11.53
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.41
|
| Rate for Payer: Medical Associates Commercial |
$17.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.42
|
| Rate for Payer: Midlands Choice Commercial |
$15.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.12
|
| Rate for Payer: United Healthcare Commercial |
$20.55
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.47
|
|
|
ketorolac 30 mg/mL Inj 1ml SDV
|
Facility
IP
|
$27.60
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
43762115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna of IA Commercial |
$24.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.84
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.70
|
| Rate for Payer: Medical Associates Commercial |
$20.70
|
| Rate for Payer: Midlands Choice Commercial |
$19.32
|
| Rate for Payer: United Healthcare Commercial |
$24.84
|
|
|
ketorolac 30 mg/mL Inj 1ml SDV
|
Facility
OP
|
$27.60
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
43762115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.79 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna of IA Commercial |
$24.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.84
|
| Rate for Payer: Aetna of IA Medicare |
$15.73
|
| Rate for Payer: Amerigroup Medicaid |
$13.93
|
| Rate for Payer: Amerigroup Medicare |
$13.94
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.79
|
| Rate for Payer: Medical Associates Commercial |
$20.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.80
|
| Rate for Payer: Midlands Choice Commercial |
$19.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.70
|
| Rate for Payer: United Healthcare Commercial |
$24.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.28
|
|
|
ketorolac 60 mg/mL 2 ml SDV inj
|
Facility
OP
|
$23.15
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
43791258
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$20.84 |
| Rate for Payer: Aetna of IA Commercial |
$20.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.84
|
| Rate for Payer: Aetna of IA Medicare |
$13.20
|
| Rate for Payer: Amerigroup Medicaid |
$11.68
|
| Rate for Payer: Amerigroup Medicare |
$11.69
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.57
|
| Rate for Payer: Medical Associates Commercial |
$17.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.58
|
| Rate for Payer: Midlands Choice Commercial |
$16.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.36
|
| Rate for Payer: United Healthcare Commercial |
$20.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.66
|
|
