|
phenol topical 1.4% Spray 177ml
|
Facility
IP
|
$11.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Aetna of IA Commercial |
$9.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.90
|
| Rate for Payer: Cash Price |
$8.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.25
|
| Rate for Payer: Medical Associates Commercial |
$8.25
|
| Rate for Payer: Midlands Choice Commercial |
$7.70
|
| Rate for Payer: United Healthcare Commercial |
$9.90
|
|
|
phenol topical 1.4% Spray 177ml
|
Facility
OP
|
$11.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Aetna of IA Commercial |
$9.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.90
|
| Rate for Payer: Aetna of IA Medicare |
$6.27
|
| Rate for Payer: Amerigroup Medicaid |
$5.55
|
| Rate for Payer: Amerigroup Medicare |
$5.56
|
| Rate for Payer: Cash Price |
$8.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.50
|
| Rate for Payer: Medical Associates Commercial |
$8.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.50
|
| Rate for Payer: Midlands Choice Commercial |
$7.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.25
|
| Rate for Payer: United Healthcare Commercial |
$9.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.49
|
|
|
phentermine 37.5 mg Cap
|
Facility
IP
|
$3.37
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Aetna of IA Commercial |
$3.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.03
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.53
|
| Rate for Payer: Medical Associates Commercial |
$2.53
|
| Rate for Payer: Midlands Choice Commercial |
$2.36
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
|
|
phentermine 37.5 mg Cap
|
Facility
OP
|
$3.37
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Aetna of IA Commercial |
$3.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.03
|
| Rate for Payer: Aetna of IA Medicare |
$1.92
|
| Rate for Payer: Amerigroup Medicaid |
$1.70
|
| Rate for Payer: Amerigroup Medicare |
$1.70
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.53
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.68
|
| Rate for Payer: Medical Associates Commercial |
$2.53
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.68
|
| Rate for Payer: Midlands Choice Commercial |
$2.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.53
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.99
|
|
|
phenylephrine 10 mg/mL 1ml SDV Inj
|
Facility
OP
|
$27.58
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
43700077
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$24.82 |
| Rate for Payer: Aetna of IA Commercial |
$24.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.82
|
| Rate for Payer: Aetna of IA Medicare |
$15.72
|
| Rate for Payer: Amerigroup Medicaid |
$13.92
|
| Rate for Payer: Amerigroup Medicare |
$13.93
|
| Rate for Payer: Cash Price |
$22.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.79
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.78
|
| Rate for Payer: Medical Associates Commercial |
$20.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.79
|
| Rate for Payer: Midlands Choice Commercial |
$19.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.68
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.27
|
|
|
phenylephrine 10 mg/mL 1ml SDV Inj
|
Facility
IP
|
$27.58
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
43700077
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.31 |
| Max. Negotiated Rate |
$24.82 |
| Rate for Payer: Aetna of IA Commercial |
$24.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.82
|
| Rate for Payer: Cash Price |
$22.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.68
|
| Rate for Payer: Medical Associates Commercial |
$20.68
|
| Rate for Payer: Midlands Choice Commercial |
$19.31
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
|
|
phenylephrine Nasal 0.5% Spry
|
Facility
IP
|
$28.08
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Aetna of IA Commercial |
$25.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.27
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.06
|
| Rate for Payer: Medical Associates Commercial |
$21.06
|
| Rate for Payer: Midlands Choice Commercial |
$19.66
|
| Rate for Payer: United Healthcare Commercial |
$25.27
|
|
|
phenylephrine Nasal 0.5% Spry
|
Facility
OP
|
$28.08
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.03 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Aetna of IA Commercial |
$25.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.27
|
| Rate for Payer: Aetna of IA Medicare |
$16.01
|
| Rate for Payer: Amerigroup Medicaid |
$14.17
|
| Rate for Payer: Amerigroup Medicare |
$14.18
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.03
|
| Rate for Payer: Medical Associates Commercial |
$21.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.04
|
| Rate for Payer: Midlands Choice Commercial |
$19.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.06
|
| Rate for Payer: United Healthcare Commercial |
$25.27
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.57
|
|
|
phenytoin 100 mg/4 ml Oral Susp
|
Facility
IP
|
$14.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43745888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: Aetna of IA Commercial |
$12.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.60
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.50
|
| Rate for Payer: Medical Associates Commercial |
$10.50
|
| Rate for Payer: Midlands Choice Commercial |
$9.80
|
| Rate for Payer: United Healthcare Commercial |
$12.60
|
|
|
phenytoin 100 mg/4 ml Oral Susp
|
Facility
OP
|
$14.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43745888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: Aetna of IA Commercial |
$12.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.60
|
| Rate for Payer: Aetna of IA Medicare |
$7.98
|
| Rate for Payer: Amerigroup Medicaid |
$7.07
|
| Rate for Payer: Amerigroup Medicare |
$7.07
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.00
|
| Rate for Payer: Medical Associates Commercial |
$10.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.00
|
| Rate for Payer: Midlands Choice Commercial |
$9.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.50
|
| Rate for Payer: United Healthcare Commercial |
$12.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.26
|
|
|
phenytoin 100 mg ER Cap
|
Facility
OP
|
$2.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701548
|
|
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
|
|
|
phenytoin 100 mg ER Cap
|
Facility
IP
|
$2.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701548
|
|
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
|
|
|
phenytoin 125 mg/5 mL Oral Susp
|
Facility
OP
|
$110.88
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.42 |
| Max. Negotiated Rate |
$99.79 |
| Rate for Payer: Aetna of IA Commercial |
$99.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.79
|
| Rate for Payer: Aetna of IA Medicare |
$63.20
|
| Rate for Payer: Amerigroup Medicaid |
$55.96
|
| Rate for Payer: Amerigroup Medicare |
$55.99
|
| Rate for Payer: Cash Price |
$88.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.42
|
| Rate for Payer: Medical Associates Commercial |
$83.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.44
|
| Rate for Payer: Midlands Choice Commercial |
$77.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.16
|
| Rate for Payer: United Healthcare Commercial |
$99.79
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.42
|
|
|
phenytoin 125 mg/5 mL Oral Susp
|
Facility
IP
|
$110.88
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701556
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.62 |
| Max. Negotiated Rate |
$99.79 |
| Rate for Payer: Aetna of IA Commercial |
$99.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.79
|
| Rate for Payer: Cash Price |
$88.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.16
|
| Rate for Payer: Medical Associates Commercial |
$83.16
|
| Rate for Payer: Midlands Choice Commercial |
$77.62
|
| Rate for Payer: United Healthcare Commercial |
$99.79
|
|
|
phenytoin 50 mg/mL 2 ml SDV Inj Sol [VDMC]
|
Facility
OP
|
$24.58
|
|
|
Service Code
|
CPT J1165
|
| Hospital Charge Code |
43799922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$22.12 |
| Rate for Payer: Aetna of IA Commercial |
$22.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.12
|
| Rate for Payer: Aetna of IA Medicare |
$14.01
|
| Rate for Payer: Amerigroup Medicaid |
$12.41
|
| Rate for Payer: Amerigroup Medicare |
$12.41
|
| Rate for Payer: Cash Price |
$19.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.29
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.29
|
| Rate for Payer: Medical Associates Commercial |
$18.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.29
|
| Rate for Payer: Midlands Choice Commercial |
$17.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.44
|
| Rate for Payer: United Healthcare Commercial |
$22.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.50
|
|
|
phenytoin 50 mg/mL 2 ml SDV Inj Sol [VDMC]
|
Facility
IP
|
$24.58
|
|
|
Service Code
|
CPT J1165
|
| Hospital Charge Code |
43799922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.21 |
| Max. Negotiated Rate |
$22.12 |
| Rate for Payer: Aetna of IA Commercial |
$22.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.12
|
| Rate for Payer: Cash Price |
$19.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.44
|
| Rate for Payer: Medical Associates Commercial |
$18.44
|
| Rate for Payer: Midlands Choice Commercial |
$17.21
|
| Rate for Payer: United Healthcare Commercial |
$22.12
|
|
|
phenytoin 50 mg/mL 5 ml SDV Inj Sol
|
Facility
OP
|
$26.60
|
|
|
Service Code
|
CPT J1165
|
| Hospital Charge Code |
43721088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.29 |
| Max. Negotiated Rate |
$23.94 |
| Rate for Payer: Aetna of IA Commercial |
$23.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.94
|
| Rate for Payer: Aetna of IA Medicare |
$15.16
|
| Rate for Payer: Amerigroup Medicaid |
$13.43
|
| Rate for Payer: Amerigroup Medicare |
$13.43
|
| Rate for Payer: Cash Price |
$21.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.29
|
| Rate for Payer: Medical Associates Commercial |
$19.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.30
|
| Rate for Payer: Midlands Choice Commercial |
$18.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.95
|
| Rate for Payer: United Healthcare Commercial |
$23.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.69
|
|
|
phenytoin 50 mg/mL 5 ml SDV Inj Sol
|
Facility
IP
|
$26.60
|
|
|
Service Code
|
CPT J1165
|
| Hospital Charge Code |
43721088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$23.94 |
| Rate for Payer: Aetna of IA Commercial |
$23.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.94
|
| Rate for Payer: Cash Price |
$21.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.95
|
| Rate for Payer: Medical Associates Commercial |
$19.95
|
| Rate for Payer: Midlands Choice Commercial |
$18.62
|
| Rate for Payer: United Healthcare Commercial |
$23.94
|
|
|
Phenytoin DMCL
|
Facility
IP
|
$131.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
8037753
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$117.90 |
| Rate for Payer: Aetna of IA Commercial |
$117.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.90
|
| Rate for Payer: Cash Price |
$104.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$98.25
|
| Rate for Payer: Medical Associates Commercial |
$98.25
|
| Rate for Payer: Midlands Choice Commercial |
$91.70
|
| Rate for Payer: United Healthcare Commercial |
$117.90
|
|
|
Phenytoin DMCL
|
Facility
OP
|
$131.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
8037753
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$117.90 |
| Rate for Payer: Aetna of IA Commercial |
$117.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$117.90
|
| Rate for Payer: Aetna of IA Medicare |
$74.67
|
| Rate for Payer: Amerigroup Medicaid |
$66.12
|
| Rate for Payer: Amerigroup Medicare |
$66.16
|
| Rate for Payer: Cash Price |
$104.80
|
| Rate for Payer: Cash Price |
$104.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$98.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$65.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.47
|
| Rate for Payer: Medical Associates Commercial |
$98.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.50
|
| Rate for Payer: Midlands Choice Commercial |
$91.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$98.25
|
| Rate for Payer: United Healthcare Commercial |
$117.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$77.29
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
PHLEBOTOMY, SCHEDULED
|
Facility
IP
|
$222.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
8012944
|
|
Hospital Revenue Code
|
949
|
| Min. Negotiated Rate |
$155.40 |
| Max. Negotiated Rate |
$199.80 |
| Rate for Payer: Aetna of IA Commercial |
$199.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$199.80
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$166.50
|
| Rate for Payer: Medical Associates Commercial |
$166.50
|
| Rate for Payer: Midlands Choice Commercial |
$155.40
|
| Rate for Payer: United Healthcare Commercial |
$199.80
|
|
|
PHLEBOTOMY, SCHEDULED
|
Facility
OP
|
$222.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
8012944
|
|
Hospital Revenue Code
|
949
|
| Min. Negotiated Rate |
$110.96 |
| Max. Negotiated Rate |
$387.38 |
| Rate for Payer: Aetna of IA Commercial |
$199.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$199.80
|
| Rate for Payer: Aetna of IA Medicare |
$126.54
|
| Rate for Payer: Amerigroup Medicaid |
$112.04
|
| Rate for Payer: Amerigroup Medicare |
$112.11
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$166.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$111.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$110.96
|
| Rate for Payer: Medical Associates Commercial |
$166.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$111.00
|
| Rate for Payer: Midlands Choice Commercial |
$155.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$112.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$166.50
|
| Rate for Payer: United Healthcare Commercial |
$199.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$130.98
|
| Rate for Payer: Wellmark IA HMO |
$352.16
|
| Rate for Payer: Wellmark IA PPO |
$387.38
|
|
|
PHOSPHOLIPID NEUTRALIZATION, PLATELET
|
Facility
OP
|
$58.00
|
|
|
Service Code
|
CPT 85597
|
| Hospital Charge Code |
8093942
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$28.99 |
| Max. Negotiated Rate |
$62.06 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Aetna of IA Medicare |
$33.06
|
| Rate for Payer: Amerigroup Medicaid |
$29.27
|
| Rate for Payer: Amerigroup Medicare |
$29.29
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.99
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.00
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$43.50
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.22
|
| Rate for Payer: Wellmark IA HMO |
$56.42
|
| Rate for Payer: Wellmark IA PPO |
$62.06
|
|
|
PHOSPHOLIPID NEUTRALIZATION, PLATELET
|
Facility
IP
|
$58.00
|
|
|
Service Code
|
CPT 85597
|
| Hospital Charge Code |
8093942
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$40.60 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of IA Commercial |
$52.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.20
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.50
|
| Rate for Payer: Medical Associates Commercial |
$43.50
|
| Rate for Payer: Midlands Choice Commercial |
$40.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
|
|
PHOSPHOROUS
|
Facility
OP
|
$45.00
|
|
|
Service Code
|
CPT 84100
|
| Hospital Charge Code |
633803
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna of IA Commercial |
$40.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$40.50
|
| Rate for Payer: Aetna of IA Medicare |
$25.65
|
| Rate for Payer: Amerigroup Medicaid |
$22.71
|
| Rate for Payer: Amerigroup Medicare |
$22.72
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.49
|
| Rate for Payer: Medical Associates Commercial |
$33.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.50
|
| Rate for Payer: Midlands Choice Commercial |
$31.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.75
|
| Rate for Payer: United Healthcare Commercial |
$40.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$26.55
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
