|
ALS2 EMERGENCY
|
Facility
OP
|
$1,187.00
|
|
|
Service Code
|
CPT A0433 QN
|
| Hospital Charge Code |
5230787
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$593.26 |
| Max. Negotiated Rate |
$1,068.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,068.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,068.30
|
| Rate for Payer: Aetna of IA Medicare |
$676.59
|
| Rate for Payer: Amerigroup Medicaid |
$599.08
|
| Rate for Payer: Amerigroup Medicare |
$599.44
|
| Rate for Payer: Cash Price |
$949.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$890.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$593.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$593.26
|
| Rate for Payer: Medical Associates Commercial |
$890.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$593.50
|
| Rate for Payer: Midlands Choice Commercial |
$830.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$602.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$890.25
|
| Rate for Payer: United Healthcare Commercial |
$1,068.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,008.95
|
|
|
ALS2 EMERGENCY
|
Facility
IP
|
$1,187.00
|
|
|
Service Code
|
CPT A0433 QN
|
| Hospital Charge Code |
5230787
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$830.90 |
| Max. Negotiated Rate |
$1,068.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,068.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,068.30
|
| Rate for Payer: Cash Price |
$949.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$890.25
|
| Rate for Payer: Medical Associates Commercial |
$890.25
|
| Rate for Payer: Midlands Choice Commercial |
$830.90
|
| Rate for Payer: United Healthcare Commercial |
$1,068.30
|
|
|
alteplase 100 mg IV Inj SDV
|
Facility
IP
|
$16,292.66
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
43785331
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,404.86 |
| Max. Negotiated Rate |
$14,663.39 |
| Rate for Payer: Aetna of IA Commercial |
$14,663.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14,663.39
|
| Rate for Payer: Cash Price |
$13,034.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12,219.50
|
| Rate for Payer: Medical Associates Commercial |
$12,219.50
|
| Rate for Payer: Midlands Choice Commercial |
$11,404.86
|
| Rate for Payer: United Healthcare Commercial |
$14,663.39
|
|
|
alteplase 100 mg IV Inj SDV
|
Facility
OP
|
$16,292.66
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
43785331
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,143.07 |
| Max. Negotiated Rate |
$14,663.39 |
| Rate for Payer: Aetna of IA Commercial |
$14,663.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14,663.39
|
| Rate for Payer: Aetna of IA Medicare |
$9,286.82
|
| Rate for Payer: Amerigroup Medicaid |
$8,222.91
|
| Rate for Payer: Amerigroup Medicare |
$8,227.79
|
| Rate for Payer: Cash Price |
$13,034.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12,219.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8,146.33
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,143.07
|
| Rate for Payer: Medical Associates Commercial |
$12,219.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$8,146.33
|
| Rate for Payer: Midlands Choice Commercial |
$11,404.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,268.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$12,219.50
|
| Rate for Payer: United Healthcare Commercial |
$14,663.39
|
| Rate for Payer: United Healthcare Managed Medicare |
$9,612.67
|
|
|
alteplase 2 mg IV Inj SDV
|
Facility
IP
|
$700.72
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
43769813
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$490.50 |
| Max. Negotiated Rate |
$630.65 |
| Rate for Payer: Aetna of IA Commercial |
$630.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$630.65
|
| Rate for Payer: Cash Price |
$560.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$525.54
|
| Rate for Payer: Medical Associates Commercial |
$525.54
|
| Rate for Payer: Midlands Choice Commercial |
$490.50
|
| Rate for Payer: United Healthcare Commercial |
$630.65
|
|
|
alteplase 2 mg IV Inj SDV
|
Facility
OP
|
$700.72
|
|
|
Service Code
|
CPT J2997
|
| Hospital Charge Code |
43769813
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$350.22 |
| Max. Negotiated Rate |
$630.65 |
| Rate for Payer: Aetna of IA Commercial |
$630.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$630.65
|
| Rate for Payer: Aetna of IA Medicare |
$399.41
|
| Rate for Payer: Amerigroup Medicaid |
$353.65
|
| Rate for Payer: Amerigroup Medicare |
$353.86
|
| Rate for Payer: Cash Price |
$560.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$525.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$350.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$350.22
|
| Rate for Payer: Medical Associates Commercial |
$525.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$350.36
|
| Rate for Payer: Midlands Choice Commercial |
$490.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$355.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$525.54
|
| Rate for Payer: United Healthcare Commercial |
$630.65
|
| Rate for Payer: United Healthcare Managed Medicare |
$413.42
|
|
|
ALT (SGPT)
|
Facility
OP
|
$51.00
|
|
|
Service Code
|
CPT 84460
|
| Hospital Charge Code |
633632
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna of IA Commercial |
$45.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.90
|
| Rate for Payer: Aetna of IA Medicare |
$29.07
|
| Rate for Payer: Amerigroup Medicaid |
$25.74
|
| Rate for Payer: Amerigroup Medicare |
$25.76
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$25.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$25.49
|
| Rate for Payer: Medical Associates Commercial |
$38.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$25.50
|
| Rate for Payer: Midlands Choice Commercial |
$35.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$38.25
|
| Rate for Payer: United Healthcare Commercial |
$45.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.09
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
ALT (SGPT)
|
Facility
IP
|
$51.00
|
|
|
Service Code
|
CPT 84460
|
| Hospital Charge Code |
633632
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna of IA Commercial |
$45.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.90
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.25
|
| Rate for Payer: Medical Associates Commercial |
$38.25
|
| Rate for Payer: Midlands Choice Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$45.90
|
|
|
amantadine 100 mg Cap
|
Facility
IP
|
$1.33
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of IA Commercial |
$1.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.20
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Midlands Choice Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
amantadine 100 mg Cap
|
Facility
OP
|
$1.33
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702558
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of IA Commercial |
$1.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.20
|
| Rate for Payer: Aetna of IA Medicare |
$0.76
|
| Rate for Payer: Amerigroup Medicaid |
$0.67
|
| Rate for Payer: Amerigroup Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.66
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.67
|
| Rate for Payer: Midlands Choice Commercial |
$0.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.78
|
|
|
amantadine 50 mg/5 mL Syr
|
Facility
OP
|
$31.77
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702156
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.88 |
| Max. Negotiated Rate |
$28.59 |
| Rate for Payer: Aetna of IA Commercial |
$28.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.59
|
| Rate for Payer: Aetna of IA Medicare |
$18.11
|
| Rate for Payer: Amerigroup Medicaid |
$16.03
|
| Rate for Payer: Amerigroup Medicare |
$16.04
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.83
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.88
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.88
|
| Rate for Payer: Medical Associates Commercial |
$23.83
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.88
|
| Rate for Payer: Midlands Choice Commercial |
$22.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.83
|
| Rate for Payer: United Healthcare Commercial |
$28.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.74
|
|
|
amantadine 50 mg/5 mL Syr
|
Facility
IP
|
$31.77
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702156
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.24 |
| Max. Negotiated Rate |
$28.59 |
| Rate for Payer: Aetna of IA Commercial |
$28.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.59
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.83
|
| Rate for Payer: Medical Associates Commercial |
$23.83
|
| Rate for Payer: Midlands Choice Commercial |
$22.24
|
| Rate for Payer: United Healthcare Commercial |
$28.59
|
|
|
AMB RESPOND TREAT/NO TRANSPORT
|
Facility
IP
|
$118.00
|
|
|
Service Code
|
CPT A0998 QN
|
| Hospital Charge Code |
7932767
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna of IA Commercial |
$106.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$106.20
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$88.50
|
| Rate for Payer: Medical Associates Commercial |
$88.50
|
| Rate for Payer: Midlands Choice Commercial |
$82.60
|
| Rate for Payer: United Healthcare Commercial |
$106.20
|
|
|
AMB RESPOND TREAT/NO TRANSPORT
|
Facility
OP
|
$118.00
|
|
|
Service Code
|
CPT A0998 QN
|
| Hospital Charge Code |
7932767
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$58.98 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna of IA Commercial |
$106.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$106.20
|
| Rate for Payer: Aetna of IA Medicare |
$67.26
|
| Rate for Payer: Amerigroup Medicaid |
$59.55
|
| Rate for Payer: Amerigroup Medicare |
$59.59
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$88.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$59.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$58.98
|
| Rate for Payer: Medical Associates Commercial |
$88.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.00
|
| Rate for Payer: Midlands Choice Commercial |
$82.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$59.88
|
| Rate for Payer: Partners Health Alliance Commercial |
$88.50
|
| Rate for Payer: United Healthcare Commercial |
$106.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.30
|
|
|
Amikacin Level Trough DMCL
|
Facility
OP
|
$62.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
8037492
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$30.99 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of IA Commercial |
$55.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.80
|
| Rate for Payer: Aetna of IA Medicare |
$35.34
|
| Rate for Payer: Amerigroup Medicaid |
$31.29
|
| Rate for Payer: Amerigroup Medicare |
$31.31
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.99
|
| Rate for Payer: Medical Associates Commercial |
$46.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.00
|
| Rate for Payer: Midlands Choice Commercial |
$43.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$46.50
|
| Rate for Payer: United Healthcare Commercial |
$55.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.58
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
Amikacin Level Trough DMCL
|
Facility
IP
|
$62.00
|
|
|
Service Code
|
CPT 80150
|
| Hospital Charge Code |
8037492
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of IA Commercial |
$55.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.80
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$46.50
|
| Rate for Payer: Medical Associates Commercial |
$46.50
|
| Rate for Payer: Midlands Choice Commercial |
$43.40
|
| Rate for Payer: United Healthcare Commercial |
$55.80
|
|
|
amiodarone 200 mg Tab
|
Facility
IP
|
$1.69
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701158
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of IA Commercial |
$1.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.52
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.27
|
| Rate for Payer: Medical Associates Commercial |
$1.27
|
| Rate for Payer: Midlands Choice Commercial |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
|
|
amiodarone 200 mg Tab
|
Facility
OP
|
$1.69
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701158
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of IA Commercial |
$1.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.52
|
| Rate for Payer: Aetna of IA Medicare |
$0.96
|
| Rate for Payer: Amerigroup Medicaid |
$0.85
|
| Rate for Payer: Amerigroup Medicare |
$0.85
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.27
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.84
|
| Rate for Payer: Medical Associates Commercial |
$1.27
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$1.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.27
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.00
|
|
|
amiodarone 400 mg Tab
|
Facility
IP
|
$5.91
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43740025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna of IA Commercial |
$5.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.32
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.43
|
| Rate for Payer: Medical Associates Commercial |
$4.43
|
| Rate for Payer: Midlands Choice Commercial |
$4.14
|
| Rate for Payer: United Healthcare Commercial |
$5.32
|
|
|
amiodarone 400 mg Tab
|
Facility
OP
|
$5.91
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43740025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna of IA Commercial |
$5.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.32
|
| Rate for Payer: Aetna of IA Medicare |
$3.37
|
| Rate for Payer: Amerigroup Medicaid |
$2.98
|
| Rate for Payer: Amerigroup Medicare |
$2.98
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.95
|
| Rate for Payer: Medical Associates Commercial |
$4.43
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.96
|
| Rate for Payer: Midlands Choice Commercial |
$4.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.43
|
| Rate for Payer: United Healthcare Commercial |
$5.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.49
|
|
|
amiodarone 50 mg/mL 18ml SDV
|
Facility
IP
|
$47.92
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
43701065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.54 |
| Max. Negotiated Rate |
$43.13 |
| Rate for Payer: Aetna of IA Commercial |
$43.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.13
|
| Rate for Payer: Cash Price |
$38.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$35.94
|
| Rate for Payer: Medical Associates Commercial |
$35.94
|
| Rate for Payer: Midlands Choice Commercial |
$33.54
|
| Rate for Payer: United Healthcare Commercial |
$43.13
|
|
|
amiodarone 50 mg/mL 18ml SDV
|
Facility
OP
|
$47.92
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
43701065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.95 |
| Max. Negotiated Rate |
$43.13 |
| Rate for Payer: Aetna of IA Commercial |
$43.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.13
|
| Rate for Payer: Aetna of IA Medicare |
$27.31
|
| Rate for Payer: Amerigroup Medicaid |
$24.19
|
| Rate for Payer: Amerigroup Medicare |
$24.20
|
| Rate for Payer: Cash Price |
$38.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$35.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.95
|
| Rate for Payer: Medical Associates Commercial |
$35.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.96
|
| Rate for Payer: Midlands Choice Commercial |
$33.54
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$35.94
|
| Rate for Payer: United Healthcare Commercial |
$43.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.27
|
|
|
amiodarone 50 mg/mL 3 ml IV Sol SDV
|
Facility
IP
|
$23.06
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
43795716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.14 |
| Max. Negotiated Rate |
$20.75 |
| Rate for Payer: Aetna of IA Commercial |
$20.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.75
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.30
|
| Rate for Payer: Medical Associates Commercial |
$17.30
|
| Rate for Payer: Midlands Choice Commercial |
$16.14
|
| Rate for Payer: United Healthcare Commercial |
$20.75
|
|
|
amiodarone 50 mg/mL 3 ml IV Sol SDV
|
Facility
OP
|
$23.06
|
|
|
Service Code
|
CPT J0282
|
| Hospital Charge Code |
43795716
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$20.75 |
| Rate for Payer: Aetna of IA Commercial |
$20.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.75
|
| Rate for Payer: Aetna of IA Medicare |
$13.14
|
| Rate for Payer: Amerigroup Medicaid |
$11.64
|
| Rate for Payer: Amerigroup Medicare |
$11.65
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.53
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.53
|
| Rate for Payer: Medical Associates Commercial |
$17.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.53
|
| Rate for Payer: Midlands Choice Commercial |
$16.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.30
|
| Rate for Payer: United Healthcare Commercial |
$20.75
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.61
|
|
|
amitriptyline 10 mg Tab
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43761257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Aetna of IA Medicare |
$0.72
|
| Rate for Payer: Amerigroup Medicaid |
$0.64
|
| Rate for Payer: Amerigroup Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.63
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.63
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
