|
loperamide 2 mg Cap
|
Facility
OP
|
$2.03
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna of IA Commercial |
$1.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.83
|
| Rate for Payer: Aetna of IA Medicare |
$1.16
|
| Rate for Payer: Amerigroup Medicaid |
$1.02
|
| Rate for Payer: Amerigroup Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.52
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.01
|
| Rate for Payer: Medical Associates Commercial |
$1.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.02
|
| Rate for Payer: Midlands Choice Commercial |
$1.42
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$1.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.20
|
|
|
loperamide 2 mg Cap
|
Facility
IP
|
$2.03
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna of IA Commercial |
$1.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.83
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.52
|
| Rate for Payer: Medical Associates Commercial |
$1.52
|
| Rate for Payer: Midlands Choice Commercial |
$1.42
|
| Rate for Payer: United Healthcare Commercial |
$1.83
|
|
|
LO-PRO LOCK SCREW, TI,3.5MMX12MM
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783530
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
LO-PRO LOCK SCREW, TI,3.5MMX12MM
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783530
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
LO-PRO LOCK SCREW, TI,3.5X14MM
|
Facility
OP
|
$270.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.95 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Aetna of IA Medicare |
$153.90
|
| Rate for Payer: Amerigroup Medicaid |
$136.27
|
| Rate for Payer: Amerigroup Medicare |
$136.35
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$135.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$134.95
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$202.50
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$159.30
|
|
|
LO-PRO LOCK SCREW, TI,3.5X14MM
|
Facility
IP
|
$270.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783532
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of IA Commercial |
$243.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$243.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$202.50
|
| Rate for Payer: Medical Associates Commercial |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$189.00
|
| Rate for Payer: United Healthcare Commercial |
$243.00
|
|
|
LO-PRO SCREW, TI, 3.5MMX10MM
|
Facility
OP
|
$108.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$53.98 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna of IA Commercial |
$97.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.20
|
| Rate for Payer: Aetna of IA Medicare |
$61.56
|
| Rate for Payer: Amerigroup Medicaid |
$54.51
|
| Rate for Payer: Amerigroup Medicare |
$54.54
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$53.98
|
| Rate for Payer: Medical Associates Commercial |
$81.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.00
|
| Rate for Payer: Midlands Choice Commercial |
$75.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.00
|
| Rate for Payer: United Healthcare Commercial |
$97.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.72
|
|
|
LO-PRO SCREW, TI, 3.5MMX10MM
|
Facility
IP
|
$108.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783218
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna of IA Commercial |
$97.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.20
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.00
|
| Rate for Payer: Medical Associates Commercial |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$75.60
|
| Rate for Payer: United Healthcare Commercial |
$97.20
|
|
|
LO-PRO SCREW,TI,3.5MMX14MM
|
Facility
IP
|
$108.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna of IA Commercial |
$97.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.20
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.00
|
| Rate for Payer: Medical Associates Commercial |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$75.60
|
| Rate for Payer: United Healthcare Commercial |
$97.20
|
|
|
LO-PRO SCREW,TI,3.5MMX14MM
|
Facility
OP
|
$108.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8783220
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$53.98 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna of IA Commercial |
$97.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.20
|
| Rate for Payer: Aetna of IA Medicare |
$61.56
|
| Rate for Payer: Amerigroup Medicaid |
$54.51
|
| Rate for Payer: Amerigroup Medicare |
$54.54
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$53.98
|
| Rate for Payer: Medical Associates Commercial |
$81.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.00
|
| Rate for Payer: Midlands Choice Commercial |
$75.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.00
|
| Rate for Payer: United Healthcare Commercial |
$97.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.72
|
|
|
loratadine 10 mg Tab
|
Facility
IP
|
$1.75
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705889
|
|
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
|
|
|
loratadine 10 mg Tab
|
Facility
OP
|
$1.75
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705889
|
|
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
|
|
|
LORazepam 0.5 mg Tab
|
Facility
IP
|
$3.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702548
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna of IA Commercial |
$2.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.92
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.44
|
| Rate for Payer: Medical Associates Commercial |
$2.44
|
| Rate for Payer: Midlands Choice Commercial |
$2.28
|
| Rate for Payer: United Healthcare Commercial |
$2.92
|
|
|
LORazepam 0.5 mg Tab
|
Facility
OP
|
$3.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702548
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna of IA Commercial |
$2.92
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.92
|
| Rate for Payer: Aetna of IA Medicare |
$1.85
|
| Rate for Payer: Amerigroup Medicaid |
$1.64
|
| Rate for Payer: Amerigroup Medicare |
$1.64
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.62
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.62
|
| Rate for Payer: Medical Associates Commercial |
$2.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.62
|
| Rate for Payer: Midlands Choice Commercial |
$2.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.44
|
| Rate for Payer: United Healthcare Commercial |
$2.92
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.92
|
|
|
LORazepam 1 mg Tab
|
Facility
OP
|
$3.15
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702546
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of IA Commercial |
$2.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.84
|
| Rate for Payer: Aetna of IA Medicare |
$1.80
|
| Rate for Payer: Amerigroup Medicaid |
$1.59
|
| Rate for Payer: Amerigroup Medicare |
$1.59
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.36
|
| 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 |
$1.57
|
| Rate for Payer: Medical Associates Commercial |
$2.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.58
|
| Rate for Payer: Midlands Choice Commercial |
$2.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.36
|
| Rate for Payer: United Healthcare Commercial |
$2.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.86
|
|
|
LORazepam 1 mg Tab
|
Facility
IP
|
$3.15
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702546
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of IA Commercial |
$2.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.84
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.36
|
| Rate for Payer: Medical Associates Commercial |
$2.36
|
| Rate for Payer: Midlands Choice Commercial |
$2.20
|
| Rate for Payer: United Healthcare Commercial |
$2.84
|
|
|
LORazepam 2 mg/mL 1ml MDV
|
Facility
IP
|
$44.20
|
|
|
Service Code
|
CPT J2060
|
| Hospital Charge Code |
43794217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$39.78 |
| Rate for Payer: Aetna of IA Commercial |
$39.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.78
|
| Rate for Payer: Cash Price |
$35.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.15
|
| Rate for Payer: Medical Associates Commercial |
$33.15
|
| Rate for Payer: Midlands Choice Commercial |
$30.94
|
| Rate for Payer: United Healthcare Commercial |
$39.78
|
|
|
LORazepam 2 mg/mL 1ml MDV
|
Facility
OP
|
$44.20
|
|
|
Service Code
|
CPT J2060
|
| Hospital Charge Code |
43794217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.09 |
| Max. Negotiated Rate |
$39.78 |
| Rate for Payer: Aetna of IA Commercial |
$39.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.78
|
| Rate for Payer: Aetna of IA Medicare |
$25.19
|
| Rate for Payer: Amerigroup Medicaid |
$22.31
|
| Rate for Payer: Amerigroup Medicare |
$22.32
|
| Rate for Payer: Cash Price |
$35.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.09
|
| Rate for Payer: Medical Associates Commercial |
$33.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.10
|
| Rate for Payer: Midlands Choice Commercial |
$30.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.15
|
| Rate for Payer: United Healthcare Commercial |
$39.78
|
| Rate for Payer: United Healthcare Managed Medicare |
$26.08
|
|
|
LORazepam 2 mg/mL 1ml Syringe
|
Facility
IP
|
$52.92
|
|
|
Service Code
|
CPT J2060
|
| Hospital Charge Code |
43788971
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.04 |
| Max. Negotiated Rate |
$47.63 |
| Rate for Payer: Aetna of IA Commercial |
$47.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.63
|
| Rate for Payer: Cash Price |
$42.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.69
|
| Rate for Payer: Medical Associates Commercial |
$39.69
|
| Rate for Payer: Midlands Choice Commercial |
$37.04
|
| Rate for Payer: United Healthcare Commercial |
$47.63
|
|
|
LORazepam 2 mg/mL 1ml Syringe
|
Facility
OP
|
$52.92
|
|
|
Service Code
|
CPT J2060
|
| Hospital Charge Code |
43788971
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.45 |
| Max. Negotiated Rate |
$47.63 |
| Rate for Payer: Aetna of IA Commercial |
$47.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.63
|
| Rate for Payer: Aetna of IA Medicare |
$30.16
|
| Rate for Payer: Amerigroup Medicaid |
$26.71
|
| Rate for Payer: Amerigroup Medicare |
$26.72
|
| Rate for Payer: Cash Price |
$42.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.45
|
| Rate for Payer: Medical Associates Commercial |
$39.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.46
|
| Rate for Payer: Midlands Choice Commercial |
$37.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.69
|
| Rate for Payer: United Healthcare Commercial |
$47.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.22
|
|
|
LORazepam 2 mg/mL 30 ml Oral Conc
|
Facility
OP
|
$42.48
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43750435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.23 |
| Max. Negotiated Rate |
$38.23 |
| Rate for Payer: Aetna of IA Commercial |
$38.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.23
|
| Rate for Payer: Aetna of IA Medicare |
$24.21
|
| Rate for Payer: Amerigroup Medicaid |
$21.44
|
| Rate for Payer: Amerigroup Medicare |
$21.45
|
| Rate for Payer: Cash Price |
$33.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.23
|
| Rate for Payer: Medical Associates Commercial |
$31.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.24
|
| Rate for Payer: Midlands Choice Commercial |
$29.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.86
|
| Rate for Payer: United Healthcare Commercial |
$38.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.06
|
|
|
LORazepam 2 mg/mL 30 ml Oral Conc
|
Facility
IP
|
$42.48
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43750435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.74 |
| Max. Negotiated Rate |
$38.23 |
| Rate for Payer: Aetna of IA Commercial |
$38.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.23
|
| Rate for Payer: Cash Price |
$33.98
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.86
|
| Rate for Payer: Medical Associates Commercial |
$31.86
|
| Rate for Payer: Midlands Choice Commercial |
$29.74
|
| Rate for Payer: United Healthcare Commercial |
$38.23
|
|
|
losartan 50 mg Tab
|
Facility
IP
|
$2.31
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702743
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna of IA Commercial |
$2.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.08
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.73
|
| Rate for Payer: Medical Associates Commercial |
$1.73
|
| Rate for Payer: Midlands Choice Commercial |
$1.62
|
| Rate for Payer: United Healthcare Commercial |
$2.08
|
|
|
losartan 50 mg Tab
|
Facility
OP
|
$2.31
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702743
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna of IA Commercial |
$2.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.08
|
| Rate for Payer: Aetna of IA Medicare |
$1.32
|
| Rate for Payer: Amerigroup Medicaid |
$1.17
|
| Rate for Payer: Amerigroup Medicare |
$1.17
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.73
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.15
|
| Rate for Payer: Medical Associates Commercial |
$1.73
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.16
|
| Rate for Payer: Midlands Choice Commercial |
$1.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.73
|
| Rate for Payer: United Healthcare Commercial |
$2.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.36
|
|
|
losartan-hydrochlorothiazide 50 mg- 12.5 mg-Tab
|
Facility
OP
|
$1.77
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705883
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Aetna of IA Commercial |
$1.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.59
|
| Rate for Payer: Aetna of IA Medicare |
$1.01
|
| Rate for Payer: Amerigroup Medicaid |
$0.89
|
| Rate for Payer: Amerigroup Medicare |
$0.89
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.33
|
| 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 |
$0.88
|
| Rate for Payer: Medical Associates Commercial |
$1.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.89
|
| Rate for Payer: Midlands Choice Commercial |
$1.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.33
|
| Rate for Payer: United Healthcare Commercial |
$1.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.04
|
|
