|
ACETABULAR SHELL SYSTEM-52E
|
Facility
IP
|
$4,358.00
|
|
|
Service Code
|
CPT L8699
|
| Hospital Charge Code |
8046816
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,050.60 |
| Max. Negotiated Rate |
$3,922.20 |
| Rate for Payer: Aetna of IA Commercial |
$3,922.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,922.20
|
| Rate for Payer: Cash Price |
$3,486.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,268.50
|
| Rate for Payer: Medical Associates Commercial |
$3,268.50
|
| Rate for Payer: Midlands Choice Commercial |
$3,050.60
|
| Rate for Payer: United Healthcare Commercial |
$3,922.20
|
|
|
ACETABULAR SHELL SYSTEM-52E
|
Facility
OP
|
$4,358.00
|
|
|
Service Code
|
CPT L8699
|
| Hospital Charge Code |
8046816
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.13 |
| Max. Negotiated Rate |
$3,922.20 |
| Rate for Payer: Aetna of IA Commercial |
$3,922.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,922.20
|
| Rate for Payer: Aetna of IA Medicare |
$2,484.06
|
| Rate for Payer: Amerigroup Medicaid |
$2,199.48
|
| Rate for Payer: Amerigroup Medicare |
$2,200.79
|
| Rate for Payer: Cash Price |
$3,486.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,268.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,179.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,178.13
|
| Rate for Payer: Medical Associates Commercial |
$3,268.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,179.00
|
| Rate for Payer: Midlands Choice Commercial |
$3,050.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,211.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,268.50
|
| Rate for Payer: United Healthcare Commercial |
$3,922.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,571.22
|
|
|
ACETABULAR SHELL SYSTEM-56F
|
Facility
OP
|
$4,358.00
|
|
|
Service Code
|
CPT L8699
|
| Hospital Charge Code |
8046818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,178.13 |
| Max. Negotiated Rate |
$3,922.20 |
| Rate for Payer: Aetna of IA Commercial |
$3,922.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,922.20
|
| Rate for Payer: Aetna of IA Medicare |
$2,484.06
|
| Rate for Payer: Amerigroup Medicaid |
$2,199.48
|
| Rate for Payer: Amerigroup Medicare |
$2,200.79
|
| Rate for Payer: Cash Price |
$3,486.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,268.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,179.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,178.13
|
| Rate for Payer: Medical Associates Commercial |
$3,268.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,179.00
|
| Rate for Payer: Midlands Choice Commercial |
$3,050.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,211.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,268.50
|
| Rate for Payer: United Healthcare Commercial |
$3,922.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,571.22
|
|
|
ACETABULAR SHELL SYSTEM-56F
|
Facility
IP
|
$4,358.00
|
|
|
Service Code
|
CPT L8699
|
| Hospital Charge Code |
8046818
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,050.60 |
| Max. Negotiated Rate |
$3,922.20 |
| Rate for Payer: Aetna of IA Commercial |
$3,922.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,922.20
|
| Rate for Payer: Cash Price |
$3,486.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,268.50
|
| Rate for Payer: Medical Associates Commercial |
$3,268.50
|
| Rate for Payer: Midlands Choice Commercial |
$3,050.60
|
| Rate for Payer: United Healthcare Commercial |
$3,922.20
|
|
|
ACETAMINOPHEN
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
1503764
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$73.47 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna of IA Commercial |
$132.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$132.30
|
| Rate for Payer: Aetna of IA Medicare |
$83.79
|
| Rate for Payer: Amerigroup Medicaid |
$74.19
|
| Rate for Payer: Amerigroup Medicare |
$74.24
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$110.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.47
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$110.25
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.73
|
| Rate for Payer: Wellmark IA HMO |
$102.92
|
| Rate for Payer: Wellmark IA PPO |
$113.21
|
|
|
ACETAMINOPHEN
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
1503764
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna of IA Commercial |
$132.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$132.30
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$110.25
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
|
|
acetaminophen 10 mg/mL 100 ml vial SDV
|
Facility
IP
|
$34.78
|
|
|
Service Code
|
CPT J0131
|
| Hospital Charge Code |
43700246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$31.30 |
| Rate for Payer: Aetna of IA Commercial |
$31.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$31.30
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.08
|
| Rate for Payer: Medical Associates Commercial |
$26.08
|
| Rate for Payer: Midlands Choice Commercial |
$24.35
|
| Rate for Payer: United Healthcare Commercial |
$31.30
|
|
|
acetaminophen 10 mg/mL 100 ml vial SDV
|
Facility
OP
|
$34.78
|
|
|
Service Code
|
CPT J0131
|
| Hospital Charge Code |
43700246
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.38 |
| Max. Negotiated Rate |
$31.30 |
| Rate for Payer: Aetna of IA Commercial |
$31.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$31.30
|
| Rate for Payer: Aetna of IA Medicare |
$19.82
|
| Rate for Payer: Amerigroup Medicaid |
$17.55
|
| Rate for Payer: Amerigroup Medicare |
$17.56
|
| Rate for Payer: Cash Price |
$27.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.39
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.38
|
| Rate for Payer: Medical Associates Commercial |
$26.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.39
|
| Rate for Payer: Midlands Choice Commercial |
$24.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.08
|
| Rate for Payer: United Healthcare Commercial |
$31.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$20.52
|
|
|
acetaminophen 160 mg/5 mL 5ml cup Sus UD
|
Facility
OP
|
$3.59
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43712359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Aetna of IA Commercial |
$3.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.23
|
| Rate for Payer: Aetna of IA Medicare |
$2.05
|
| Rate for Payer: Amerigroup Medicaid |
$1.81
|
| Rate for Payer: Amerigroup Medicare |
$1.81
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.79
|
| Rate for Payer: Medical Associates Commercial |
$2.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.80
|
| Rate for Payer: Midlands Choice Commercial |
$2.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.69
|
| Rate for Payer: United Healthcare Commercial |
$3.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.12
|
|
|
acetaminophen 160 mg/5 mL 5ml cup Sus UD
|
Facility
IP
|
$3.59
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43712359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$3.23 |
| Rate for Payer: Aetna of IA Commercial |
$3.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.23
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.69
|
| Rate for Payer: Medical Associates Commercial |
$2.69
|
| Rate for Payer: Midlands Choice Commercial |
$2.51
|
| Rate for Payer: United Healthcare Commercial |
$3.23
|
|
|
acetaminophen 325 mg Supp
|
Facility
IP
|
$5.30
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna of IA Commercial |
$4.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.77
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.98
|
| Rate for Payer: Medical Associates Commercial |
$3.98
|
| Rate for Payer: Midlands Choice Commercial |
$3.71
|
| Rate for Payer: United Healthcare Commercial |
$4.77
|
|
|
acetaminophen 325 mg Supp
|
Facility
OP
|
$5.30
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$4.77 |
| Rate for Payer: Aetna of IA Commercial |
$4.77
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.77
|
| Rate for Payer: Aetna of IA Medicare |
$3.02
|
| Rate for Payer: Amerigroup Medicaid |
$2.67
|
| Rate for Payer: Amerigroup Medicare |
$2.68
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.65
|
| Rate for Payer: Medical Associates Commercial |
$3.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.65
|
| Rate for Payer: Midlands Choice Commercial |
$3.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.98
|
| Rate for Payer: United Healthcare Commercial |
$4.77
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.13
|
|
|
acetaminophen 650 mg Sup
|
Facility
OP
|
$4.11
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702002
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna of IA Commercial |
$3.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.70
|
| Rate for Payer: Aetna of IA Medicare |
$2.34
|
| Rate for Payer: Amerigroup Medicaid |
$2.07
|
| Rate for Payer: Amerigroup Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$3.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.05
|
| Rate for Payer: Medical Associates Commercial |
$3.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.06
|
| Rate for Payer: Midlands Choice Commercial |
$2.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.08
|
| Rate for Payer: United Healthcare Commercial |
$3.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.42
|
|
|
acetaminophen 650 mg Sup
|
Facility
IP
|
$4.11
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702002
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna of IA Commercial |
$3.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.70
|
| Rate for Payer: Cash Price |
$3.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.08
|
| Rate for Payer: Medical Associates Commercial |
$3.08
|
| Rate for Payer: Midlands Choice Commercial |
$2.88
|
| Rate for Payer: United Healthcare Commercial |
$3.70
|
|
|
acetaminophen-codeine
|
Facility
OP
|
$3.90
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Aetna of IA Commercial |
$3.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.51
|
| Rate for Payer: Aetna of IA Medicare |
$2.22
|
| Rate for Payer: Amerigroup Medicaid |
$1.97
|
| Rate for Payer: Amerigroup Medicare |
$1.97
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.95
|
| Rate for Payer: Medical Associates Commercial |
$2.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.95
|
| Rate for Payer: Midlands Choice Commercial |
$2.73
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.92
|
| Rate for Payer: United Healthcare Commercial |
$3.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.30
|
|
|
acetaminophen-codeine
|
Facility
IP
|
$3.90
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Aetna of IA Commercial |
$3.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.51
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.92
|
| Rate for Payer: Medical Associates Commercial |
$2.92
|
| Rate for Payer: Midlands Choice Commercial |
$2.73
|
| Rate for Payer: United Healthcare Commercial |
$3.51
|
|
|
acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 5 mL
|
Facility
IP
|
$3.22
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701469
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Aetna of IA Commercial |
$2.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.90
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.42
|
| Rate for Payer: Medical Associates Commercial |
$2.42
|
| Rate for Payer: Midlands Choice Commercial |
$2.25
|
| Rate for Payer: United Healthcare Commercial |
$2.90
|
|
|
acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 5 mL
|
Facility
OP
|
$3.22
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701469
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Aetna of IA Commercial |
$2.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.90
|
| Rate for Payer: Aetna of IA Medicare |
$1.84
|
| Rate for Payer: Amerigroup Medicaid |
$1.63
|
| Rate for Payer: Amerigroup Medicare |
$1.63
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.61
|
| Rate for Payer: Medical Associates Commercial |
$2.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.61
|
| Rate for Payer: Midlands Choice Commercial |
$2.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.42
|
| Rate for Payer: United Healthcare Commercial |
$2.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.90
|
|
|
acetaminophen-HYDROcodone 325 MG-7.5 MG/15 mL
|
Facility
IP
|
$6.76
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706254
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Aetna of IA Commercial |
$6.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.08
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.07
|
| Rate for Payer: Medical Associates Commercial |
$5.07
|
| Rate for Payer: Midlands Choice Commercial |
$4.73
|
| Rate for Payer: United Healthcare Commercial |
$6.08
|
|
|
acetaminophen-HYDROcodone 325 MG-7.5 MG/15 mL
|
Facility
OP
|
$6.76
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706254
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$6.08 |
| Rate for Payer: Aetna of IA Commercial |
$6.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.08
|
| Rate for Payer: Aetna of IA Medicare |
$3.85
|
| Rate for Payer: Amerigroup Medicaid |
$3.41
|
| Rate for Payer: Amerigroup Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$5.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.38
|
| Rate for Payer: Medical Associates Commercial |
$5.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.38
|
| Rate for Payer: Midlands Choice Commercial |
$4.73
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.07
|
| Rate for Payer: United Healthcare Commercial |
$6.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.99
|
|
|
acetaminophen-oxyCODONE 325 mg-5 mg Tab
|
Facility
OP
|
$3.87
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$3.48 |
| Rate for Payer: Aetna of IA Commercial |
$3.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.48
|
| Rate for Payer: Aetna of IA Medicare |
$2.21
|
| Rate for Payer: Amerigroup Medicaid |
$1.95
|
| Rate for Payer: Amerigroup Medicare |
$1.95
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.94
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.93
|
| Rate for Payer: Medical Associates Commercial |
$2.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.94
|
| Rate for Payer: Midlands Choice Commercial |
$2.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.90
|
| Rate for Payer: United Healthcare Commercial |
$3.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.28
|
|
|
acetaminophen-oxyCODONE 325 mg-5 mg Tab
|
Facility
IP
|
$3.87
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$3.48 |
| Rate for Payer: Aetna of IA Commercial |
$3.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.48
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.90
|
| Rate for Payer: Medical Associates Commercial |
$2.90
|
| Rate for Payer: Midlands Choice Commercial |
$2.71
|
| Rate for Payer: United Healthcare Commercial |
$3.48
|
|
|
acetaZOLAMIDE 250 mg Tab
|
Facility
OP
|
$3.29
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna of IA Commercial |
$2.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.96
|
| Rate for Payer: Aetna of IA Medicare |
$1.88
|
| Rate for Payer: Amerigroup Medicaid |
$1.66
|
| Rate for Payer: Amerigroup Medicare |
$1.66
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.47
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.64
|
| Rate for Payer: Medical Associates Commercial |
$2.47
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.64
|
| Rate for Payer: Midlands Choice Commercial |
$2.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.47
|
| Rate for Payer: United Healthcare Commercial |
$2.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.94
|
|
|
acetaZOLAMIDE 250 mg Tab
|
Facility
IP
|
$3.29
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna of IA Commercial |
$2.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.96
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.47
|
| Rate for Payer: Medical Associates Commercial |
$2.47
|
| Rate for Payer: Midlands Choice Commercial |
$2.30
|
| Rate for Payer: United Healthcare Commercial |
$2.96
|
|
|
Acetylcholine Recep Bind Ab DMCL
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
8037484
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna of IA Commercial |
$132.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$132.30
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$110.25
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
|
