|
levothyroxine 112 mcg (0.112 mg) Tab
|
Facility
OP
|
$1.22
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43751303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Aetna of IA Medicare |
$0.70
|
| Rate for Payer: Amerigroup Medicaid |
$0.62
|
| Rate for Payer: Amerigroup Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.92
|
| 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 |
$0.61
|
| Rate for Payer: Medical Associates Commercial |
$0.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.61
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.72
|
|
|
levothyroxine 112 mcg (0.112 mg) Tab
|
Facility
IP
|
$1.22
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43751303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.92
|
| Rate for Payer: Medical Associates Commercial |
$0.92
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
|
|
levothyroxine 125 mcg (0.125 mg) Tab
|
Facility
OP
|
$1.75
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702108
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Aetna of IA Commercial |
$1.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.58
|
| Rate for Payer: Aetna of IA Medicare |
$1.00
|
| Rate for Payer: Amerigroup Medicaid |
$0.88
|
| Rate for Payer: Amerigroup Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.31
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.87
|
| Rate for Payer: Medical Associates Commercial |
$1.31
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.88
|
| Rate for Payer: Midlands Choice Commercial |
$1.22
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.03
|
|
|
levothyroxine 125 mcg (0.125 mg) Tab
|
Facility
IP
|
$1.75
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702108
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Aetna of IA Commercial |
$1.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.58
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.31
|
| Rate for Payer: Medical Associates Commercial |
$1.31
|
| Rate for Payer: Midlands Choice Commercial |
$1.22
|
| Rate for Payer: United Healthcare Commercial |
$1.58
|
|
|
levothyroxine 25 mcg (0.025 mg) Tab
|
Facility
IP
|
$2.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43732258
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Midlands Choice Commercial |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
|
|
levothyroxine 25 mcg (0.025 mg) Tab
|
Facility
OP
|
$2.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43732258
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna of IA Commercial |
$2.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.02
|
| Rate for Payer: Aetna of IA Medicare |
$1.28
|
| Rate for Payer: Amerigroup Medicaid |
$1.14
|
| Rate for Payer: Amerigroup Medicare |
$1.14
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.69
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
|
levothyroxine 50 mcg (0.05 mg) Tab
|
Facility
OP
|
$2.85
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43799927
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna of IA Commercial |
$2.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.56
|
| Rate for Payer: Aetna of IA Medicare |
$1.62
|
| Rate for Payer: Amerigroup Medicaid |
$1.44
|
| Rate for Payer: Amerigroup Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.42
|
| Rate for Payer: Medical Associates Commercial |
$2.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.42
|
| Rate for Payer: Midlands Choice Commercial |
$2.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.45
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.14
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.68
|
|
|
levothyroxine 50 mcg (0.05 mg) Tab
|
Facility
IP
|
$2.85
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43799927
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna of IA Commercial |
$2.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.14
|
| Rate for Payer: Medical Associates Commercial |
$2.14
|
| Rate for Payer: Midlands Choice Commercial |
$2.00
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
|
|
levothyroxine 75 mcg (0.075 mg) Tab
|
Facility
IP
|
$2.28
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna of IA Commercial |
$2.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.05
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.71
|
| Rate for Payer: Medical Associates Commercial |
$1.71
|
| Rate for Payer: Midlands Choice Commercial |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$2.05
|
|
|
levothyroxine 75 mcg (0.075 mg) Tab
|
Facility
OP
|
$2.28
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna of IA Commercial |
$2.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.05
|
| Rate for Payer: Aetna of IA Medicare |
$1.30
|
| Rate for Payer: Amerigroup Medicaid |
$1.15
|
| Rate for Payer: Amerigroup Medicare |
$1.15
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.14
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.14
|
| Rate for Payer: Medical Associates Commercial |
$1.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.14
|
| Rate for Payer: Midlands Choice Commercial |
$1.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.16
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.71
|
| Rate for Payer: United Healthcare Commercial |
$2.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.35
|
|
|
levothyroxine 88 mcg (0.088 mg) Tab
|
Facility
OP
|
$1.40
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of IA Commercial |
$1.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.26
|
| Rate for Payer: Aetna of IA Medicare |
$0.80
|
| Rate for Payer: Amerigroup Medicaid |
$0.71
|
| Rate for Payer: Amerigroup Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.05
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.70
|
| Rate for Payer: Medical Associates Commercial |
$1.05
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.70
|
| Rate for Payer: Midlands Choice Commercial |
$0.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.83
|
|
|
levothyroxine 88 mcg (0.088 mg) Tab
|
Facility
IP
|
$1.40
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of IA Commercial |
$1.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.26
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.05
|
| Rate for Payer: Medical Associates Commercial |
$1.05
|
| Rate for Payer: Midlands Choice Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
|
|
lidocaine 1% 10 ml MDV
|
Facility
IP
|
$28.98
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43700337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.29 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna of IA Commercial |
$26.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.08
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.74
|
| Rate for Payer: Medical Associates Commercial |
$21.74
|
| Rate for Payer: Midlands Choice Commercial |
$20.29
|
| Rate for Payer: United Healthcare Commercial |
$26.08
|
|
|
lidocaine 1% 10 ml MDV
|
Facility
OP
|
$28.98
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43700337
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna of IA Commercial |
$26.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.08
|
| Rate for Payer: Aetna of IA Medicare |
$16.52
|
| Rate for Payer: Amerigroup Medicaid |
$14.63
|
| Rate for Payer: Amerigroup Medicare |
$14.63
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.74
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.49
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.48
|
| Rate for Payer: Medical Associates Commercial |
$21.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.49
|
| Rate for Payer: Midlands Choice Commercial |
$20.29
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.74
|
| Rate for Payer: United Healthcare Commercial |
$26.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.10
|
|
|
lidocaine 1% 200mg/20ml MDV 20ml
|
Facility
IP
|
$25.84
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43700368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.09 |
| Max. Negotiated Rate |
$23.26 |
| Rate for Payer: Aetna of IA Commercial |
$23.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.26
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.38
|
| Rate for Payer: Medical Associates Commercial |
$19.38
|
| Rate for Payer: Midlands Choice Commercial |
$18.09
|
| Rate for Payer: United Healthcare Commercial |
$23.26
|
|
|
lidocaine 1% 200mg/20ml MDV 20ml
|
Facility
OP
|
$25.84
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43700368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$23.26 |
| Rate for Payer: Aetna of IA Commercial |
$23.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.26
|
| Rate for Payer: Aetna of IA Medicare |
$14.73
|
| Rate for Payer: Amerigroup Medicaid |
$13.04
|
| Rate for Payer: Amerigroup Medicare |
$13.05
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.91
|
| Rate for Payer: Medical Associates Commercial |
$19.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.92
|
| Rate for Payer: Midlands Choice Commercial |
$18.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.38
|
| Rate for Payer: United Healthcare Commercial |
$23.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.25
|
|
|
lidocaine 1% 20mg/2 mL PF SDV
|
Facility
IP
|
$23.11
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43702124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.18 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.80
|
| Rate for Payer: Cash Price |
$18.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.33
|
| Rate for Payer: Medical Associates Commercial |
$17.33
|
| Rate for Payer: Midlands Choice Commercial |
$16.18
|
| Rate for Payer: United Healthcare Commercial |
$20.80
|
|
|
lidocaine 1% 20mg/2 mL PF SDV
|
Facility
OP
|
$23.11
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43702124
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$20.80 |
| Rate for Payer: Aetna of IA Commercial |
$20.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.80
|
| Rate for Payer: Aetna of IA Medicare |
$13.17
|
| Rate for Payer: Amerigroup Medicaid |
$11.66
|
| Rate for Payer: Amerigroup Medicare |
$11.67
|
| Rate for Payer: Cash Price |
$18.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.55
|
| Rate for Payer: Medical Associates Commercial |
$17.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.56
|
| Rate for Payer: Midlands Choice Commercial |
$16.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.33
|
| Rate for Payer: United Healthcare Commercial |
$20.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.63
|
|
|
lidocaine 1% 30 mL PF SDV
|
Facility
OP
|
$63.38
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43786196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna of IA Commercial |
$57.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.04
|
| Rate for Payer: Aetna of IA Medicare |
$36.13
|
| Rate for Payer: Amerigroup Medicaid |
$31.99
|
| Rate for Payer: Amerigroup Medicare |
$32.01
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.69
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.68
|
| Rate for Payer: Medical Associates Commercial |
$47.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.69
|
| Rate for Payer: Midlands Choice Commercial |
$44.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.54
|
| Rate for Payer: United Healthcare Commercial |
$57.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.39
|
|
|
lidocaine 1% 30 mL PF SDV
|
Facility
IP
|
$63.38
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43786196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.37 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna of IA Commercial |
$57.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.04
|
| Rate for Payer: Cash Price |
$50.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.54
|
| Rate for Payer: Medical Associates Commercial |
$47.54
|
| Rate for Payer: Midlands Choice Commercial |
$44.37
|
| Rate for Payer: United Healthcare Commercial |
$57.04
|
|
|
lidocaine 1% 5 ml PF SDV
|
Facility
OP
|
$24.33
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43707888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.16 |
| Max. Negotiated Rate |
$21.90 |
| Rate for Payer: Aetna of IA Commercial |
$21.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.90
|
| Rate for Payer: Aetna of IA Medicare |
$13.87
|
| Rate for Payer: Amerigroup Medicaid |
$12.28
|
| Rate for Payer: Amerigroup Medicare |
$12.29
|
| Rate for Payer: Cash Price |
$19.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.16
|
| Rate for Payer: Medical Associates Commercial |
$18.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.16
|
| Rate for Payer: Midlands Choice Commercial |
$17.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.25
|
| Rate for Payer: United Healthcare Commercial |
$21.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.35
|
|
|
lidocaine 1% 5 ml PF SDV
|
Facility
IP
|
$24.33
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43707888
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$21.90 |
| Rate for Payer: Aetna of IA Commercial |
$21.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.90
|
| Rate for Payer: Cash Price |
$19.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.25
|
| Rate for Payer: Medical Associates Commercial |
$18.25
|
| Rate for Payer: Midlands Choice Commercial |
$17.03
|
| Rate for Payer: United Healthcare Commercial |
$21.90
|
|
|
Lidocaine 1% Phenylephrine 1.5% Opht PF Syringe
|
Facility
IP
|
$83.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.10 |
| Max. Negotiated Rate |
$74.70 |
| Rate for Payer: Aetna of IA Commercial |
$74.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$74.70
|
| Rate for Payer: Cash Price |
$66.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$62.25
|
| Rate for Payer: Medical Associates Commercial |
$62.25
|
| Rate for Payer: Midlands Choice Commercial |
$58.10
|
| Rate for Payer: United Healthcare Commercial |
$74.70
|
|
|
Lidocaine 1% Phenylephrine 1.5% Opht PF Syringe
|
Facility
OP
|
$83.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.48 |
| Max. Negotiated Rate |
$74.70 |
| Rate for Payer: Aetna of IA Commercial |
$74.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$74.70
|
| Rate for Payer: Aetna of IA Medicare |
$47.31
|
| Rate for Payer: Amerigroup Medicaid |
$41.89
|
| Rate for Payer: Amerigroup Medicare |
$41.92
|
| Rate for Payer: Cash Price |
$66.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$62.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$41.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$41.48
|
| Rate for Payer: Medical Associates Commercial |
$62.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$41.50
|
| Rate for Payer: Midlands Choice Commercial |
$58.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$42.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$62.25
|
| Rate for Payer: United Healthcare Commercial |
$74.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.97
|
|
|
lidocaine 2% 200mg/10 mL MDV
|
Facility
OP
|
$26.92
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
43701617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.45 |
| Max. Negotiated Rate |
$24.23 |
| Rate for Payer: Aetna of IA Commercial |
$24.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.23
|
| Rate for Payer: Aetna of IA Medicare |
$15.34
|
| Rate for Payer: Amerigroup Medicaid |
$13.59
|
| Rate for Payer: Amerigroup Medicare |
$13.59
|
| Rate for Payer: Cash Price |
$21.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.45
|
| Rate for Payer: Medical Associates Commercial |
$20.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.46
|
| Rate for Payer: Midlands Choice Commercial |
$18.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.19
|
| Rate for Payer: United Healthcare Commercial |
$24.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.88
|
|
