|
levETIRAcetam 100 mg/mL 5ml cup Oral Sol
|
Facility
IP
|
$13.70
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43791477
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Aetna of IA Commercial |
$12.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.33
|
| Rate for Payer: Cash Price |
$10.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.28
|
| Rate for Payer: Medical Associates Commercial |
$10.28
|
| Rate for Payer: Midlands Choice Commercial |
$9.59
|
| Rate for Payer: United Healthcare Commercial |
$12.33
|
|
|
levETIRAcetam 500 mg/5ml Vial
|
Facility
OP
|
$24.92
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
43700385
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.46 |
| Max. Negotiated Rate |
$22.43 |
| Rate for Payer: Aetna of IA Commercial |
$22.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.43
|
| Rate for Payer: Aetna of IA Medicare |
$14.20
|
| Rate for Payer: Amerigroup Medicaid |
$12.58
|
| Rate for Payer: Amerigroup Medicare |
$12.58
|
| Rate for Payer: Cash Price |
$19.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.46
|
| Rate for Payer: Medical Associates Commercial |
$18.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.46
|
| Rate for Payer: Midlands Choice Commercial |
$17.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.69
|
| Rate for Payer: United Healthcare Commercial |
$22.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.70
|
|
|
levETIRAcetam 500 mg/5ml Vial
|
Facility
IP
|
$24.92
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
43700385
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$22.43 |
| Rate for Payer: Aetna of IA Commercial |
$22.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.43
|
| Rate for Payer: Cash Price |
$19.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.69
|
| Rate for Payer: Medical Associates Commercial |
$18.69
|
| Rate for Payer: Midlands Choice Commercial |
$17.44
|
| Rate for Payer: United Healthcare Commercial |
$22.43
|
|
|
levETIRAcetam 500 mg Tab
|
Facility
OP
|
$1.53
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43740540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of IA Commercial |
$1.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.38
|
| Rate for Payer: Aetna of IA Medicare |
$0.87
|
| Rate for Payer: Amerigroup Medicaid |
$0.77
|
| Rate for Payer: Amerigroup Medicare |
$0.77
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.76
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.77
|
| Rate for Payer: Midlands Choice Commercial |
$1.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.90
|
|
|
levETIRAcetam 500 mg Tab
|
Facility
IP
|
$1.53
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43740540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of IA Commercial |
$1.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.38
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Midlands Choice Commercial |
$1.07
|
| Rate for Payer: United Healthcare Commercial |
$1.38
|
|
|
levofloxacin 250 mg/50 mL IV Sol
|
Facility
IP
|
$55.11
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
43706087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$49.60 |
| Rate for Payer: Aetna of IA Commercial |
$49.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.60
|
| Rate for Payer: Cash Price |
$44.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.33
|
| Rate for Payer: Medical Associates Commercial |
$41.33
|
| Rate for Payer: Midlands Choice Commercial |
$38.58
|
| Rate for Payer: United Healthcare Commercial |
$49.60
|
|
|
levofloxacin 250 mg/50 mL IV Sol
|
Facility
OP
|
$55.11
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
43706087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.54 |
| Max. Negotiated Rate |
$49.60 |
| Rate for Payer: Aetna of IA Commercial |
$49.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.60
|
| Rate for Payer: Aetna of IA Medicare |
$31.41
|
| Rate for Payer: Amerigroup Medicaid |
$27.81
|
| Rate for Payer: Amerigroup Medicare |
$27.83
|
| Rate for Payer: Cash Price |
$44.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.33
|
| 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 |
$27.54
|
| Rate for Payer: Medical Associates Commercial |
$41.33
|
| 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 |
$41.33
|
| Rate for Payer: United Healthcare Commercial |
$49.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$32.51
|
|
|
levofloxacin 500 mg/100 mL IV Sol
|
Facility
IP
|
$56.87
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
43705940
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.81 |
| Max. Negotiated Rate |
$51.18 |
| Rate for Payer: Aetna of IA Commercial |
$51.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.18
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.65
|
| Rate for Payer: Medical Associates Commercial |
$42.65
|
| Rate for Payer: Midlands Choice Commercial |
$39.81
|
| Rate for Payer: United Healthcare Commercial |
$51.18
|
|
|
levofloxacin 500 mg/100 mL IV Sol
|
Facility
OP
|
$56.87
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
43705940
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.42 |
| Max. Negotiated Rate |
$51.18 |
| Rate for Payer: Aetna of IA Commercial |
$51.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.18
|
| Rate for Payer: Aetna of IA Medicare |
$32.42
|
| Rate for Payer: Amerigroup Medicaid |
$28.70
|
| Rate for Payer: Amerigroup Medicare |
$28.72
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.65
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.42
|
| Rate for Payer: Medical Associates Commercial |
$42.65
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.44
|
| Rate for Payer: Midlands Choice Commercial |
$39.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$28.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.65
|
| Rate for Payer: United Healthcare Commercial |
$51.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.55
|
|
|
levofloxacin 500 mg Tab UD
|
Facility
IP
|
$1.78
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705886
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of IA Commercial |
$1.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.60
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.34
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: United Healthcare Commercial |
$1.60
|
|
|
levofloxacin 500 mg Tab UD
|
Facility
OP
|
$1.78
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705886
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of IA Commercial |
$1.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.60
|
| Rate for Payer: Aetna of IA Medicare |
$1.01
|
| Rate for Payer: Amerigroup Medicaid |
$0.90
|
| Rate for Payer: Amerigroup Medicare |
$0.90
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$1.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.89
|
| Rate for Payer: Midlands Choice Commercial |
$1.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.05
|
|
|
levofloxacin 750 mg/150 mL IV Sol
|
Facility
IP
|
$57.20
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
43721406
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.04 |
| Max. Negotiated Rate |
$51.48 |
| Rate for Payer: Aetna of IA Commercial |
$51.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.48
|
| Rate for Payer: Cash Price |
$45.76
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.90
|
| Rate for Payer: Medical Associates Commercial |
$42.90
|
| Rate for Payer: Midlands Choice Commercial |
$40.04
|
| Rate for Payer: United Healthcare Commercial |
$51.48
|
|
|
levofloxacin 750 mg/150 mL IV Sol
|
Facility
OP
|
$57.20
|
|
|
Service Code
|
CPT J1956
|
| Hospital Charge Code |
43721406
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.59 |
| Max. Negotiated Rate |
$51.48 |
| Rate for Payer: Aetna of IA Commercial |
$51.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.48
|
| Rate for Payer: Aetna of IA Medicare |
$32.60
|
| Rate for Payer: Amerigroup Medicaid |
$28.87
|
| Rate for Payer: Amerigroup Medicare |
$28.89
|
| Rate for Payer: Cash Price |
$45.76
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.59
|
| Rate for Payer: Medical Associates Commercial |
$42.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.60
|
| Rate for Payer: Midlands Choice Commercial |
$40.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.90
|
| Rate for Payer: United Healthcare Commercial |
$51.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.75
|
|
|
LEVOleucovorin 10 mg/mL 25ml
|
Facility
IP
|
$673.20
|
|
|
Service Code
|
CPT J0641
|
| Hospital Charge Code |
43700049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$471.24 |
| Max. Negotiated Rate |
$605.88 |
| Rate for Payer: Aetna of IA Commercial |
$605.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$605.88
|
| Rate for Payer: Cash Price |
$538.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$504.90
|
| Rate for Payer: Medical Associates Commercial |
$504.90
|
| Rate for Payer: Midlands Choice Commercial |
$471.24
|
| Rate for Payer: United Healthcare Commercial |
$605.88
|
|
|
LEVOleucovorin 10 mg/mL 25ml
|
Facility
OP
|
$673.20
|
|
|
Service Code
|
CPT J0641
|
| Hospital Charge Code |
43700049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$336.47 |
| Max. Negotiated Rate |
$605.88 |
| Rate for Payer: Aetna of IA Commercial |
$605.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$605.88
|
| Rate for Payer: Aetna of IA Medicare |
$383.72
|
| Rate for Payer: Amerigroup Medicaid |
$339.76
|
| Rate for Payer: Amerigroup Medicare |
$339.97
|
| Rate for Payer: Cash Price |
$538.56
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$504.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$336.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$336.47
|
| Rate for Payer: Medical Associates Commercial |
$504.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$336.60
|
| Rate for Payer: Midlands Choice Commercial |
$471.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$341.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$504.90
|
| Rate for Payer: United Healthcare Commercial |
$605.88
|
| Rate for Payer: United Healthcare Managed Medicare |
$397.19
|
|
|
levonorgestrel 13.5 mg Dev
|
Facility
OP
|
$1,613.74
|
|
|
Service Code
|
CPT J7301
|
| Hospital Charge Code |
43700460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$806.55 |
| Max. Negotiated Rate |
$1,452.37 |
| Rate for Payer: Aetna of IA Commercial |
$1,452.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,452.37
|
| Rate for Payer: Aetna of IA Medicare |
$919.83
|
| Rate for Payer: Amerigroup Medicaid |
$814.45
|
| Rate for Payer: Amerigroup Medicare |
$814.94
|
| Rate for Payer: Cash Price |
$1,290.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,210.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$806.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$806.55
|
| Rate for Payer: Medical Associates Commercial |
$1,210.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$806.87
|
| Rate for Payer: Midlands Choice Commercial |
$1,129.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$818.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,210.30
|
| Rate for Payer: United Healthcare Commercial |
$1,452.37
|
| Rate for Payer: United Healthcare Managed Medicare |
$952.11
|
|
|
levonorgestrel 13.5 mg Dev
|
Facility
IP
|
$1,613.74
|
|
|
Service Code
|
CPT J7301
|
| Hospital Charge Code |
43700460
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,129.62 |
| Max. Negotiated Rate |
$1,452.37 |
| Rate for Payer: Aetna of IA Commercial |
$1,452.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,452.37
|
| Rate for Payer: Cash Price |
$1,290.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,210.30
|
| Rate for Payer: Medical Associates Commercial |
$1,210.30
|
| Rate for Payer: Midlands Choice Commercial |
$1,129.62
|
| Rate for Payer: United Healthcare Commercial |
$1,452.37
|
|
|
levonorgestrel 1.5 mg Tab [VDMC]
|
Facility
IP
|
$12.16
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700338
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna of IA Commercial |
$10.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.94
|
| Rate for Payer: Cash Price |
$9.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.12
|
| Rate for Payer: Medical Associates Commercial |
$9.12
|
| Rate for Payer: Midlands Choice Commercial |
$8.51
|
| Rate for Payer: United Healthcare Commercial |
$10.94
|
|
|
levonorgestrel 1.5 mg Tab [VDMC]
|
Facility
OP
|
$12.16
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700338
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna of IA Commercial |
$10.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.94
|
| Rate for Payer: Aetna of IA Medicare |
$6.93
|
| Rate for Payer: Amerigroup Medicaid |
$6.14
|
| Rate for Payer: Amerigroup Medicare |
$6.14
|
| Rate for Payer: Cash Price |
$9.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.08
|
| Rate for Payer: Medical Associates Commercial |
$9.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.08
|
| Rate for Payer: Midlands Choice Commercial |
$8.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.12
|
| Rate for Payer: United Healthcare Commercial |
$10.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.17
|
|
|
levonorgestrel 52 mg Dev 3 yrs
|
Facility
OP
|
$3,388.40
|
|
|
Service Code
|
CPT J7297
|
| Hospital Charge Code |
43700470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,693.52 |
| Max. Negotiated Rate |
$3,049.56 |
| Rate for Payer: Aetna of IA Commercial |
$3,049.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,049.56
|
| Rate for Payer: Aetna of IA Medicare |
$1,931.39
|
| Rate for Payer: Amerigroup Medicaid |
$1,710.13
|
| Rate for Payer: Amerigroup Medicare |
$1,711.14
|
| Rate for Payer: Cash Price |
$2,710.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,541.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,694.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,693.52
|
| Rate for Payer: Medical Associates Commercial |
$2,541.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,694.20
|
| Rate for Payer: Midlands Choice Commercial |
$2,371.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,719.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,541.30
|
| Rate for Payer: United Healthcare Commercial |
$3,049.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,999.16
|
|
|
levonorgestrel 52 mg Dev 3 yrs
|
Facility
IP
|
$3,388.40
|
|
|
Service Code
|
CPT J7297
|
| Hospital Charge Code |
43700470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,371.88 |
| Max. Negotiated Rate |
$3,049.56 |
| Rate for Payer: Aetna of IA Commercial |
$3,049.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,049.56
|
| Rate for Payer: Cash Price |
$2,710.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,541.30
|
| Rate for Payer: Medical Associates Commercial |
$2,541.30
|
| Rate for Payer: Midlands Choice Commercial |
$2,371.88
|
| Rate for Payer: United Healthcare Commercial |
$3,049.56
|
|
|
levonorgestrel 52 mg Dev 5 yrs
|
Facility
IP
|
$2,171.20
|
|
|
Service Code
|
CPT J7298
|
| Hospital Charge Code |
43700465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,519.84 |
| Max. Negotiated Rate |
$1,954.08 |
| Rate for Payer: Aetna of IA Commercial |
$1,954.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,954.08
|
| Rate for Payer: Cash Price |
$1,736.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,628.40
|
| Rate for Payer: Medical Associates Commercial |
$1,628.40
|
| Rate for Payer: Midlands Choice Commercial |
$1,519.84
|
| Rate for Payer: United Healthcare Commercial |
$1,954.08
|
|
|
levonorgestrel 52 mg Dev 5 yrs
|
Facility
OP
|
$2,171.20
|
|
|
Service Code
|
CPT J7298
|
| Hospital Charge Code |
43700465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,085.17 |
| Max. Negotiated Rate |
$1,954.08 |
| Rate for Payer: Aetna of IA Commercial |
$1,954.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,954.08
|
| Rate for Payer: Aetna of IA Medicare |
$1,237.58
|
| Rate for Payer: Amerigroup Medicaid |
$1,095.80
|
| Rate for Payer: Amerigroup Medicare |
$1,096.46
|
| Rate for Payer: Cash Price |
$1,736.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,628.40
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,085.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,085.17
|
| Rate for Payer: Medical Associates Commercial |
$1,628.40
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,085.60
|
| Rate for Payer: Midlands Choice Commercial |
$1,519.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,101.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,628.40
|
| Rate for Payer: United Healthcare Commercial |
$1,954.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,281.01
|
|
|
levothyroxine 100 mcg (0.1 mg) Tab
|
Facility
OP
|
$3.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Aetna of IA Commercial |
$2.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.85
|
| Rate for Payer: Aetna of IA Medicare |
$1.81
|
| Rate for Payer: Amerigroup Medicaid |
$1.60
|
| Rate for Payer: Amerigroup Medicare |
$1.60
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.58
|
| Rate for Payer: Medical Associates Commercial |
$2.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.58
|
| Rate for Payer: Midlands Choice Commercial |
$2.22
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.38
|
| Rate for Payer: United Healthcare Commercial |
$2.85
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.87
|
|
|
levothyroxine 100 mcg (0.1 mg) Tab
|
Facility
IP
|
$3.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Aetna of IA Commercial |
$2.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.85
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.38
|
| Rate for Payer: Medical Associates Commercial |
$2.38
|
| Rate for Payer: Midlands Choice Commercial |
$2.22
|
| Rate for Payer: United Healthcare Commercial |
$2.85
|
|
