|
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
|
|
|
phenol topical 1.4% Spray 177ml [VDMC]
|
Facility
|
IP
|
$11.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222199
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.01 |
| Max. Negotiated Rate |
$10.30 |
| Rate for Payer: Aetna of IA Commercial |
$10.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.30
|
| Rate for Payer: Cash Price |
$9.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.58
|
| Rate for Payer: Medical Associates Commercial |
$8.58
|
| Rate for Payer: Midlands Choice Commercial |
$8.01
|
| Rate for Payer: United Healthcare Commercial |
$10.30
|
|
|
phenol topical 1.4% Spray 177ml [VDMC]
|
Facility
|
OP
|
$11.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11222199
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$10.30 |
| Rate for Payer: Aetna of IA Commercial |
$10.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.30
|
| Rate for Payer: Aetna of IA Medicare |
$6.52
|
| Rate for Payer: Amerigroup Medicaid |
$6.60
|
| Rate for Payer: Amerigroup Medicare |
$5.20
|
| Rate for Payer: Cash Price |
$9.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.58
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.54
|
| Rate for Payer: Medical Associates Commercial |
$8.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.15
|
| Rate for Payer: Midlands Choice Commercial |
$8.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.92
|
| Rate for Payer: United Healthcare Commercial |
$10.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.75
|
|
|
phenol topical 89% Swab[VDMC]
|
Facility
|
OP
|
$28.01
|
|
|
Service Code
|
NDC 00884-6297-30
|
| Hospital Charge Code |
12535014
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.61 |
| Max. Negotiated Rate |
$25.21 |
| Rate for Payer: Aetna of IA Commercial |
$25.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.21
|
| Rate for Payer: Aetna of IA Medicare |
$15.97
|
| Rate for Payer: Amerigroup Medicaid |
$16.16
|
| Rate for Payer: Amerigroup Medicare |
$12.73
|
| Rate for Payer: Cash Price |
$22.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.00
|
| Rate for Payer: Medical Associates Commercial |
$21.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.61
|
| Rate for Payer: Midlands Choice Commercial |
$19.61
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.50
|
| Rate for Payer: United Healthcare Commercial |
$25.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.53
|
|
|
phenol topical 89% Swab[VDMC]
|
Facility
|
IP
|
$28.01
|
|
|
Service Code
|
NDC 00884-6297-30
|
| Hospital Charge Code |
12535014
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.61 |
| Max. Negotiated Rate |
$25.21 |
| Rate for Payer: Aetna of IA Commercial |
$25.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.21
|
| Rate for Payer: Cash Price |
$22.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.01
|
| Rate for Payer: Medical Associates Commercial |
$21.01
|
| Rate for Payer: Midlands Choice Commercial |
$19.61
|
| Rate for Payer: United Healthcare Commercial |
$25.21
|
|
|
phentermine 37.5 mg Cap [VDMC]
|
Facility
|
OP
|
$3.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
22327406
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| 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 |
$1.94
|
| Rate for Payer: Amerigroup Medicare |
$1.53
|
| 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 |
$1.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.92
|
| Rate for Payer: Medical Associates Commercial |
$2.53
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.52
|
| Rate for Payer: Midlands Choice Commercial |
$2.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$3.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.99
|
|
|
phentermine 37.5 mg Cap [VDMC]
|
Facility
|
IP
|
$3.37
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
22327406
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
phenylephrine 10 mg/mL 1ml SDV Inj [VDMC]
|
Facility
|
IP
|
$27.58
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
10413096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.30 |
| 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 |
$19.30
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
|
|
phenylephrine 10 mg/mL 1ml SDV Inj [VDMC]
|
Facility
|
OP
|
$27.58
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
10413096
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.41 |
| Max. Negotiated Rate |
$221.80 |
| 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 |
$15.91
|
| Rate for Payer: Amerigroup Medicare |
$12.53
|
| Rate for Payer: Cash Price |
$22.06
|
| 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 |
$12.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.75
|
| Rate for Payer: Medical Associates Commercial |
$20.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.41
|
| Rate for Payer: Midlands Choice Commercial |
$19.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.27
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.27
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
phenylephrine Nasal 0.5% Spry [VDMC]
|
Facility
|
IP
|
$30.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$27.25 |
| Rate for Payer: Aetna of IA Commercial |
$27.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.25
|
| Rate for Payer: Cash Price |
$24.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.71
|
| Rate for Payer: Medical Associates Commercial |
$22.71
|
| Rate for Payer: Midlands Choice Commercial |
$21.20
|
| Rate for Payer: United Healthcare Commercial |
$27.25
|
|
|
phenylephrine Nasal 0.5% Spry [VDMC]
|
Facility
|
OP
|
$30.28
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10436776
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$27.25 |
| Rate for Payer: Aetna of IA Commercial |
$27.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.25
|
| Rate for Payer: Aetna of IA Medicare |
$17.26
|
| Rate for Payer: Amerigroup Medicaid |
$17.47
|
| Rate for Payer: Amerigroup Medicare |
$13.76
|
| Rate for Payer: Cash Price |
$24.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.30
|
| Rate for Payer: Medical Associates Commercial |
$22.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.63
|
| Rate for Payer: Midlands Choice Commercial |
$21.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.67
|
| Rate for Payer: United Healthcare Commercial |
$27.25
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.87
|
|
|
phenylephrine ophthalmic 2.5% 2 ml SDV [VDMC]
|
Facility
|
IP
|
$121.92
|
|
|
Service Code
|
NDC 70756-0629-25
|
| Hospital Charge Code |
11613338
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$85.34 |
| Max. Negotiated Rate |
$109.73 |
| Rate for Payer: Aetna of IA Commercial |
$109.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$109.73
|
| Rate for Payer: Cash Price |
$97.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$91.44
|
| Rate for Payer: Medical Associates Commercial |
$91.44
|
| Rate for Payer: Midlands Choice Commercial |
$85.34
|
| Rate for Payer: United Healthcare Commercial |
$109.73
|
|
|
phenylephrine ophthalmic 2.5% 2 ml SDV [VDMC]
|
Facility
|
OP
|
$121.92
|
|
|
Service Code
|
NDC 70756-0629-25
|
| Hospital Charge Code |
11613338
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$54.86 |
| Max. Negotiated Rate |
$109.73 |
| Rate for Payer: Aetna of IA Commercial |
$109.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$109.73
|
| Rate for Payer: Aetna of IA Medicare |
$69.49
|
| Rate for Payer: Amerigroup Medicaid |
$70.32
|
| Rate for Payer: Amerigroup Medicare |
$55.41
|
| Rate for Payer: Cash Price |
$97.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$91.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.64
|
| Rate for Payer: Medical Associates Commercial |
$91.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.86
|
| Rate for Payer: Midlands Choice Commercial |
$85.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.09
|
| Rate for Payer: United Healthcare Commercial |
$109.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$71.93
|
|
|
phenytoin 100 mg/4 ml Oral Susp [VDMC]
|
Facility
|
IP
|
$18.83
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10432102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.18 |
| Max. Negotiated Rate |
$16.94 |
| Rate for Payer: Aetna of IA Commercial |
$16.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.94
|
| Rate for Payer: Cash Price |
$15.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.12
|
| Rate for Payer: Medical Associates Commercial |
$14.12
|
| Rate for Payer: Midlands Choice Commercial |
$13.18
|
| Rate for Payer: United Healthcare Commercial |
$16.94
|
|
|
phenytoin 100 mg/4 ml Oral Susp [VDMC]
|
Facility
|
OP
|
$18.83
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10432102
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$16.94 |
| Rate for Payer: Aetna of IA Commercial |
$16.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.94
|
| Rate for Payer: Aetna of IA Medicare |
$10.73
|
| Rate for Payer: Amerigroup Medicaid |
$10.86
|
| Rate for Payer: Amerigroup Medicare |
$8.56
|
| Rate for Payer: Cash Price |
$15.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10.75
|
| Rate for Payer: Medical Associates Commercial |
$14.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.47
|
| Rate for Payer: Midlands Choice Commercial |
$13.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.74
|
| Rate for Payer: United Healthcare Commercial |
$16.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$11.11
|
|
|
phenytoin 100 mg ER Cap [VDMC]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10413165
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Aetna of IA Commercial |
$2.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.03
|
| 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 |
$2.03
|
|
|
phenytoin 100 mg ER Cap [VDMC]
|
Facility
|
OP
|
$2.25
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10413165
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.03 |
| Rate for Payer: Aetna of IA Commercial |
$2.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.03
|
| Rate for Payer: Aetna of IA Medicare |
$1.28
|
| Rate for Payer: Amerigroup Medicaid |
$1.30
|
| Rate for Payer: Amerigroup Medicare |
$1.02
|
| 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 |
$1.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.29
|
| Rate for Payer: Medical Associates Commercial |
$1.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.01
|
| Rate for Payer: Midlands Choice Commercial |
$1.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
|
phenytoin 50 mg/mL 2 ml SDV Inj Sol [VDMC]
|
Facility
|
IP
|
$24.58
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
24854394
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.20 |
| 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 |
$18.43
|
| Rate for Payer: Medical Associates Commercial |
$18.43
|
| Rate for Payer: Midlands Choice Commercial |
$17.20
|
| Rate for Payer: United Healthcare Commercial |
$22.12
|
|
|
phenytoin 50 mg/mL 2 ml SDV Inj Sol [VDMC]
|
Facility
|
OP
|
$24.58
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
24854394
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$221.80 |
| 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 |
$14.18
|
| Rate for Payer: Amerigroup Medicare |
$11.17
|
| Rate for Payer: Cash Price |
$19.66
|
| Rate for Payer: Cash Price |
$19.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.04
|
| Rate for Payer: Medical Associates Commercial |
$18.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.06
|
| Rate for Payer: Midlands Choice Commercial |
$17.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.72
|
| Rate for Payer: United Healthcare Commercial |
$22.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.50
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
phenytoin 50 mg/mL 5 ml SDV Inj Sol [VDMC]
|
Facility
|
OP
|
$26.60
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
10432165
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.97 |
| Max. Negotiated Rate |
$221.80 |
| 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 |
$15.34
|
| Rate for Payer: Amerigroup Medicare |
$12.09
|
| Rate for Payer: Cash Price |
$21.28
|
| 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 |
$11.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.19
|
| Rate for Payer: Medical Associates Commercial |
$19.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.97
|
| Rate for Payer: Midlands Choice Commercial |
$18.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.77
|
| Rate for Payer: United Healthcare Commercial |
$23.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.69
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
phenytoin 50 mg/mL 5 ml SDV Inj Sol [VDMC]
|
Facility
|
IP
|
$26.60
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
10432165
|
|
Hospital Revenue Code
|
259
|
| 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 |
$58.95 |
| 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 |
$75.56
|
| Rate for Payer: Amerigroup Medicare |
$59.54
|
| 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 |
$58.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.83
|
| Rate for Payer: Medical Associates Commercial |
$98.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.95
|
| Rate for Payer: Midlands Choice Commercial |
$91.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$75.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$67.79
|
| Rate for Payer: United Healthcare Commercial |
$117.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$77.29
|
| Rate for Payer: Wellmark IA HMO WHPI |
$65.23
|
| Rate for Payer: Wellmark IA PPO |
$71.85
|
|
|
PHLEBOTOMY
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
4866809
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$93.15 |
| Max. Negotiated Rate |
$459.23 |
| Rate for Payer: Aetna of IA Commercial |
$186.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$186.30
|
| Rate for Payer: Aetna of IA Medicare |
$117.99
|
| Rate for Payer: Amerigroup Medicaid |
$119.40
|
| Rate for Payer: Amerigroup Medicare |
$94.08
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$155.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$93.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$118.24
|
| Rate for Payer: Medical Associates Commercial |
$155.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$93.15
|
| Rate for Payer: Midlands Choice Commercial |
$144.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$119.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$107.12
|
| Rate for Payer: United Healthcare Commercial |
$186.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$122.13
|
| Rate for Payer: Wellmark IA HMO WHPI |
$416.89
|
| Rate for Payer: Wellmark IA PPO |
$459.23
|
|
|
PHLEBOTOMY
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
4866809
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$144.90 |
| Max. Negotiated Rate |
$186.30 |
| Rate for Payer: Aetna of IA Commercial |
$186.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$186.30
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$155.25
|
| Rate for Payer: Medical Associates Commercial |
$155.25
|
| Rate for Payer: Midlands Choice Commercial |
$144.90
|
| Rate for Payer: United Healthcare Commercial |
$186.30
|
|
