|
zolpidem 5 mg Tab
|
Facility
IP
|
$3.21
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43755133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of IA Commercial |
$2.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.89
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.41
|
| Rate for Payer: Medical Associates Commercial |
$2.41
|
| Rate for Payer: Midlands Choice Commercial |
$2.25
|
| Rate for Payer: United Healthcare Commercial |
$2.89
|
|
|
zolpidem 5 mg Tab
|
Facility
OP
|
$3.21
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43755133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna of IA Commercial |
$2.89
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.89
|
| Rate for Payer: Aetna of IA Medicare |
$1.83
|
| Rate for Payer: Amerigroup Medicaid |
$1.62
|
| Rate for Payer: Amerigroup Medicare |
$1.62
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.41
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.60
|
| Rate for Payer: Medical Associates Commercial |
$2.41
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.60
|
| Rate for Payer: Midlands Choice Commercial |
$2.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.41
|
| Rate for Payer: United Healthcare Commercial |
$2.89
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.89
|
|
|
zonisamide 100 mg Cap
|
Facility
IP
|
$2.54
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna of IA Commercial |
$2.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.29
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.90
|
| Rate for Payer: Medical Associates Commercial |
$1.90
|
| Rate for Payer: Midlands Choice Commercial |
$1.78
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
|
|
zonisamide 100 mg Cap
|
Facility
OP
|
$2.54
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna of IA Commercial |
$2.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.29
|
| Rate for Payer: Aetna of IA Medicare |
$1.45
|
| Rate for Payer: Amerigroup Medicaid |
$1.28
|
| Rate for Payer: Amerigroup Medicare |
$1.28
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.27
|
| Rate for Payer: Medical Associates Commercial |
$1.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.27
|
| Rate for Payer: Midlands Choice Commercial |
$1.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.29
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.90
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.50
|
|
|
zonisamide 50 mg Cap
|
Facility
IP
|
$1.45
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
43700140
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.09
|
| Rate for Payer: Medical Associates Commercial |
$1.09
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
|
|
zonisamide 50 mg Cap
|
Facility
OP
|
$1.45
|
|
|
Service Code
|
CPT 90750
|
| Hospital Charge Code |
43700140
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$228.47 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Aetna of IA Medicare |
$0.83
|
| Rate for Payer: Amerigroup Medicaid |
$0.73
|
| Rate for Payer: Amerigroup Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.72
|
| Rate for Payer: Medical Associates Commercial |
$1.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.73
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.86
|
| Rate for Payer: Wellmark IA HMO |
$207.70
|
| Rate for Payer: Wellmark IA PPO |
$228.47
|
|
|
zoster vaccine recombinant IM Injection kit 50 and older
|
Facility
OP
|
$365.85
|
|
|
Service Code
|
NDC 58160-0823-11
|
| Hospital Charge Code |
43700140
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.85 |
| Max. Negotiated Rate |
$329.26 |
| Rate for Payer: Aetna of IA Commercial |
$329.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$329.26
|
| Rate for Payer: Aetna of IA Medicare |
$208.53
|
| Rate for Payer: Amerigroup Medicaid |
$184.64
|
| Rate for Payer: Amerigroup Medicare |
$184.75
|
| Rate for Payer: Cash Price |
$292.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$274.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$182.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$182.85
|
| Rate for Payer: Medical Associates Commercial |
$274.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$182.92
|
| Rate for Payer: Midlands Choice Commercial |
$256.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$185.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$274.39
|
| Rate for Payer: United Healthcare Commercial |
$329.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$215.85
|
|
|
zoster vaccine recombinant IM Injection kit 50 and older
|
Facility
IP
|
$365.85
|
|
|
Service Code
|
NDC 58160-0823-11
|
| Hospital Charge Code |
43700140
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$256.10 |
| Max. Negotiated Rate |
$329.26 |
| Rate for Payer: Aetna of IA Commercial |
$329.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$329.26
|
| Rate for Payer: Cash Price |
$292.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$274.39
|
| Rate for Payer: Medical Associates Commercial |
$274.39
|
| Rate for Payer: Midlands Choice Commercial |
$256.10
|
| Rate for Payer: United Healthcare Commercial |
$329.26
|
|
