|
PETITE MPJ PLATE, RIGHT
|
Facility
IP
|
$297.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8812766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$207.90 |
| Max. Negotiated Rate |
$267.30 |
| Rate for Payer: Aetna of IA Commercial |
$267.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$267.30
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$222.75
|
| Rate for Payer: Medical Associates Commercial |
$222.75
|
| Rate for Payer: Midlands Choice Commercial |
$207.90
|
| Rate for Payer: United Healthcare Commercial |
$267.30
|
|
|
PETITE STEPPED MPG VLC GRIDLOCK PLATE RT
|
Facility
OP
|
$2,070.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8757684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,034.59 |
| Max. Negotiated Rate |
$1,863.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,863.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,863.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,179.90
|
| Rate for Payer: Amerigroup Medicaid |
$1,044.73
|
| Rate for Payer: Amerigroup Medicare |
$1,045.35
|
| Rate for Payer: Cash Price |
$1,656.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,552.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,035.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,034.59
|
| Rate for Payer: Medical Associates Commercial |
$1,552.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,035.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,449.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,050.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,552.50
|
| Rate for Payer: United Healthcare Commercial |
$1,863.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,221.30
|
|
|
PETITE STEPPED MPG VLC GRIDLOCK PLATE RT
|
Facility
IP
|
$2,070.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8757684
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.00 |
| Max. Negotiated Rate |
$1,863.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,863.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,863.00
|
| Rate for Payer: Cash Price |
$1,656.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,552.50
|
| Rate for Payer: Medical Associates Commercial |
$1,552.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,449.00
|
| Rate for Payer: United Healthcare Commercial |
$1,863.00
|
|
|
petrolatum topical Ointment 396 gram Jar
|
Facility
OP
|
$48.44
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700546
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.21 |
| Max. Negotiated Rate |
$43.60 |
| Rate for Payer: Aetna of IA Commercial |
$43.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.60
|
| Rate for Payer: Aetna of IA Medicare |
$27.61
|
| Rate for Payer: Amerigroup Medicaid |
$24.45
|
| Rate for Payer: Amerigroup Medicare |
$24.46
|
| Rate for Payer: Cash Price |
$38.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.21
|
| Rate for Payer: Medical Associates Commercial |
$36.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.22
|
| Rate for Payer: Midlands Choice Commercial |
$33.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.33
|
| Rate for Payer: United Healthcare Commercial |
$43.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.58
|
|
|
petrolatum topical Ointment 396 gram Jar
|
Facility
IP
|
$48.44
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700546
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.91 |
| Max. Negotiated Rate |
$43.60 |
| Rate for Payer: Aetna of IA Commercial |
$43.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.60
|
| Rate for Payer: Cash Price |
$38.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.33
|
| Rate for Payer: Medical Associates Commercial |
$36.33
|
| Rate for Payer: Midlands Choice Commercial |
$33.91
|
| Rate for Payer: United Healthcare Commercial |
$43.60
|
|
|
PET w/ CT Scan Brain
|
Facility
OP
|
$4,611.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
7960817
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$2,304.58 |
| Max. Negotiated Rate |
$4,149.90 |
| Rate for Payer: Aetna of IA Commercial |
$4,149.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,149.90
|
| Rate for Payer: Aetna of IA Medicare |
$2,628.27
|
| Rate for Payer: Amerigroup Medicaid |
$2,327.17
|
| Rate for Payer: Amerigroup Medicare |
$2,328.56
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,458.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,305.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,304.58
|
| Rate for Payer: Medical Associates Commercial |
$3,458.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,305.50
|
| Rate for Payer: Midlands Choice Commercial |
$3,227.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,340.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,458.25
|
| Rate for Payer: United Healthcare Commercial |
$4,149.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,720.49
|
| Rate for Payer: Wellmark IA HMO |
$2,927.02
|
| Rate for Payer: Wellmark IA PPO |
$3,219.72
|
|
|
PET w/ CT Scan Brain
|
Facility
IP
|
$4,611.00
|
|
|
Service Code
|
CPT 78608
|
| Hospital Charge Code |
7960817
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$3,227.70 |
| Max. Negotiated Rate |
$4,149.90 |
| Rate for Payer: Aetna of IA Commercial |
$4,149.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,149.90
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,458.25
|
| Rate for Payer: Medical Associates Commercial |
$3,458.25
|
| Rate for Payer: Midlands Choice Commercial |
$3,227.70
|
| Rate for Payer: United Healthcare Commercial |
$4,149.90
|
|
|
PET w/ CT Scan Skull Base to Midthigh
|
Facility
OP
|
$4,611.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
1169558
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$2,304.58 |
| Max. Negotiated Rate |
$4,149.90 |
| Rate for Payer: Aetna of IA Commercial |
$4,149.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,149.90
|
| Rate for Payer: Aetna of IA Medicare |
$2,628.27
|
| Rate for Payer: Amerigroup Medicaid |
$2,327.17
|
| Rate for Payer: Amerigroup Medicare |
$2,328.56
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,458.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,305.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,304.58
|
| Rate for Payer: Medical Associates Commercial |
$3,458.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,305.50
|
| Rate for Payer: Midlands Choice Commercial |
$3,227.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,340.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,458.25
|
| Rate for Payer: United Healthcare Commercial |
$4,149.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,720.49
|
| Rate for Payer: Wellmark IA HMO |
$2,927.02
|
| Rate for Payer: Wellmark IA PPO |
$3,219.72
|
|
|
PET w/ CT Scan Skull Base to Midthigh
|
Facility
IP
|
$4,611.00
|
|
|
Service Code
|
CPT 78815
|
| Hospital Charge Code |
1169558
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$3,227.70 |
| Max. Negotiated Rate |
$4,149.90 |
| Rate for Payer: Aetna of IA Commercial |
$4,149.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,149.90
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,458.25
|
| Rate for Payer: Medical Associates Commercial |
$3,458.25
|
| Rate for Payer: Midlands Choice Commercial |
$3,227.70
|
| Rate for Payer: United Healthcare Commercial |
$4,149.90
|
|
|
PET w/ CT Scan Whole Body
|
Facility
IP
|
$4,611.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
1169560
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$3,227.70 |
| Max. Negotiated Rate |
$4,149.90 |
| Rate for Payer: Aetna of IA Commercial |
$4,149.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,149.90
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,458.25
|
| Rate for Payer: Medical Associates Commercial |
$3,458.25
|
| Rate for Payer: Midlands Choice Commercial |
$3,227.70
|
| Rate for Payer: United Healthcare Commercial |
$4,149.90
|
|
|
PET w/ CT Scan Whole Body
|
Facility
OP
|
$4,611.00
|
|
|
Service Code
|
CPT 78816
|
| Hospital Charge Code |
1169560
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$2,304.58 |
| Max. Negotiated Rate |
$4,149.90 |
| Rate for Payer: Aetna of IA Commercial |
$4,149.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,149.90
|
| Rate for Payer: Aetna of IA Medicare |
$2,628.27
|
| Rate for Payer: Amerigroup Medicaid |
$2,327.17
|
| Rate for Payer: Amerigroup Medicare |
$2,328.56
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Cash Price |
$3,688.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,458.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,305.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,304.58
|
| Rate for Payer: Medical Associates Commercial |
$3,458.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,305.50
|
| Rate for Payer: Midlands Choice Commercial |
$3,227.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,340.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,458.25
|
| Rate for Payer: United Healthcare Commercial |
$4,149.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,720.49
|
| Rate for Payer: Wellmark IA HMO |
$2,927.02
|
| Rate for Payer: Wellmark IA PPO |
$3,219.72
|
|
|
PH
|
Facility
IP
|
$61.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
4022833
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
|
|
PH
|
Facility
OP
|
$61.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
4022833
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Aetna of IA Medicare |
$34.77
|
| Rate for Payer: Amerigroup Medicaid |
$30.79
|
| Rate for Payer: Amerigroup Medicare |
$30.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.49
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.50
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.75
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.99
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
phenazopyridine 200 mg Tab
|
Facility
OP
|
$1.77
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706272
|
|
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
|
|
|
phenazopyridine 200 mg Tab
|
Facility
IP
|
$1.77
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| 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: Cash Price |
$1.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.33
|
| Rate for Payer: Medical Associates Commercial |
$1.33
|
| Rate for Payer: Midlands Choice Commercial |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.59
|
|
|
PHENobarbital 130 mg/ml 1ml MDV Inj Sol
|
Facility
IP
|
$53.39
|
|
|
Service Code
|
CPT J2560
|
| Hospital Charge Code |
43755971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.37 |
| Max. Negotiated Rate |
$48.05 |
| Rate for Payer: Aetna of IA Commercial |
$48.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.05
|
| Rate for Payer: Cash Price |
$42.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.04
|
| Rate for Payer: Medical Associates Commercial |
$40.04
|
| Rate for Payer: Midlands Choice Commercial |
$37.37
|
| Rate for Payer: United Healthcare Commercial |
$48.05
|
|
|
PHENobarbital 130 mg/ml 1ml MDV Inj Sol
|
Facility
OP
|
$53.39
|
|
|
Service Code
|
CPT J2560
|
| Hospital Charge Code |
43755971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.68 |
| Max. Negotiated Rate |
$48.05 |
| Rate for Payer: Aetna of IA Commercial |
$48.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.05
|
| Rate for Payer: Aetna of IA Medicare |
$30.43
|
| Rate for Payer: Amerigroup Medicaid |
$26.95
|
| Rate for Payer: Amerigroup Medicare |
$26.96
|
| Rate for Payer: Cash Price |
$42.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.04
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.68
|
| Rate for Payer: Medical Associates Commercial |
$40.04
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.70
|
| Rate for Payer: Midlands Choice Commercial |
$37.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.04
|
| Rate for Payer: United Healthcare Commercial |
$48.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.50
|
|
|
PHENobarbital 20 mg/5 mL Oral Elix
|
Facility
OP
|
$3.78
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702158
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna of IA Commercial |
$3.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.40
|
| Rate for Payer: Aetna of IA Medicare |
$2.15
|
| Rate for Payer: Amerigroup Medicaid |
$1.91
|
| Rate for Payer: Amerigroup Medicare |
$1.91
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.89
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.89
|
| Rate for Payer: Medical Associates Commercial |
$2.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.89
|
| Rate for Payer: Midlands Choice Commercial |
$2.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.84
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.23
|
|
|
PHENobarbital 20 mg/5 mL Oral Elix
|
Facility
IP
|
$3.78
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702158
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna of IA Commercial |
$3.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.40
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.84
|
| Rate for Payer: Medical Associates Commercial |
$2.84
|
| Rate for Payer: Midlands Choice Commercial |
$2.65
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
|
|
PHENobarbital 32.4 mg Tab
|
Facility
OP
|
$3.54
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna of IA Commercial |
$3.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.19
|
| Rate for Payer: Aetna of IA Medicare |
$2.02
|
| Rate for Payer: Amerigroup Medicaid |
$1.79
|
| Rate for Payer: Amerigroup Medicare |
$1.79
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.77
|
| Rate for Payer: Medical Associates Commercial |
$2.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.77
|
| Rate for Payer: Midlands Choice Commercial |
$2.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.66
|
| Rate for Payer: United Healthcare Commercial |
$3.19
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.09
|
|
|
PHENobarbital 32.4 mg Tab
|
Facility
IP
|
$3.54
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna of IA Commercial |
$3.19
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.19
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.66
|
| Rate for Payer: Medical Associates Commercial |
$2.66
|
| Rate for Payer: Midlands Choice Commercial |
$2.48
|
| Rate for Payer: United Healthcare Commercial |
$3.19
|
|
|
PHENobarbital 65 mg/ml 1ml MDV Inj
|
Facility
IP
|
$115.41
|
|
|
Service Code
|
CPT J2560
|
| Hospital Charge Code |
43701018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.79 |
| Max. Negotiated Rate |
$103.87 |
| Rate for Payer: Aetna of IA Commercial |
$103.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.87
|
| Rate for Payer: Cash Price |
$92.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.56
|
| Rate for Payer: Medical Associates Commercial |
$86.56
|
| Rate for Payer: Midlands Choice Commercial |
$80.79
|
| Rate for Payer: United Healthcare Commercial |
$103.87
|
|
|
PHENobarbital 65 mg/ml 1ml MDV Inj
|
Facility
OP
|
$115.41
|
|
|
Service Code
|
CPT J2560
|
| Hospital Charge Code |
43701018
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$103.87 |
| Rate for Payer: Aetna of IA Commercial |
$103.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.87
|
| Rate for Payer: Aetna of IA Medicare |
$65.78
|
| Rate for Payer: Amerigroup Medicaid |
$58.25
|
| Rate for Payer: Amerigroup Medicare |
$58.28
|
| Rate for Payer: Cash Price |
$92.33
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.56
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$57.68
|
| Rate for Payer: Medical Associates Commercial |
$86.56
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.70
|
| Rate for Payer: Midlands Choice Commercial |
$80.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$58.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$86.56
|
| Rate for Payer: United Healthcare Commercial |
$103.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$68.09
|
|
|
Phenobarbital Level DMCL
|
Facility
OP
|
$94.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
8037752
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$46.98 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna of IA Commercial |
$84.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$84.60
|
| Rate for Payer: Aetna of IA Medicare |
$53.58
|
| Rate for Payer: Amerigroup Medicaid |
$47.44
|
| Rate for Payer: Amerigroup Medicare |
$47.47
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$70.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$47.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$46.98
|
| Rate for Payer: Medical Associates Commercial |
$70.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$47.00
|
| Rate for Payer: Midlands Choice Commercial |
$65.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$47.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$70.50
|
| Rate for Payer: United Healthcare Commercial |
$84.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$55.46
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
Phenobarbital Level DMCL
|
Facility
IP
|
$94.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
8037752
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna of IA Commercial |
$84.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$84.60
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$70.50
|
| Rate for Payer: Medical Associates Commercial |
$70.50
|
| Rate for Payer: Midlands Choice Commercial |
$65.80
|
| Rate for Payer: United Healthcare Commercial |
$84.60
|
|
