|
buPROPion 100 mg ER Tab/12 HR
|
Facility
OP
|
$3.11
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706158
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna of IA Commercial |
$2.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.80
|
| Rate for Payer: Aetna of IA Medicare |
$1.77
|
| Rate for Payer: Amerigroup Medicaid |
$1.57
|
| Rate for Payer: Amerigroup Medicare |
$1.57
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.55
|
| Rate for Payer: Medical Associates Commercial |
$2.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.56
|
| Rate for Payer: Midlands Choice Commercial |
$2.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.33
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.83
|
|
|
buPROPion 150 mg/24 hours ER Tab
|
Facility
OP
|
$4.43
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43754371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Aetna of IA Commercial |
$3.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.99
|
| Rate for Payer: Aetna of IA Medicare |
$2.53
|
| Rate for Payer: Amerigroup Medicaid |
$2.24
|
| Rate for Payer: Amerigroup Medicare |
$2.24
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.32
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.21
|
| Rate for Payer: Medical Associates Commercial |
$3.32
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.22
|
| Rate for Payer: Midlands Choice Commercial |
$3.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.32
|
| Rate for Payer: United Healthcare Commercial |
$3.99
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.61
|
|
|
buPROPion 150 mg/24 hours ER Tab
|
Facility
IP
|
$4.43
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43754371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Aetna of IA Commercial |
$3.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.99
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.32
|
| Rate for Payer: Medical Associates Commercial |
$3.32
|
| Rate for Payer: Midlands Choice Commercial |
$3.10
|
| Rate for Payer: United Healthcare Commercial |
$3.99
|
|
|
buPROPion 150 mg ER Tab/12 HR
|
Facility
IP
|
$2.26
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705893
|
|
Hospital Revenue Code
|
637
|
| 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 |
$1.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.70
|
| Rate for Payer: Medical Associates Commercial |
$1.70
|
| Rate for Payer: Midlands Choice Commercial |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
|
|
buPROPion 150 mg ER Tab/12 HR
|
Facility
OP
|
$2.26
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| 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 |
$1.29
|
| Rate for Payer: Amerigroup Medicaid |
$1.14
|
| Rate for Payer: Amerigroup Medicare |
$1.14
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.13
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.13
|
| Rate for Payer: Medical Associates Commercial |
$1.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.13
|
| Rate for Payer: Midlands Choice Commercial |
$1.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.70
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.33
|
|
|
busPIRone 5 mg Tab
|
Facility
IP
|
$1.07
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701794
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of IA Commercial |
$0.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.96
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.80
|
| Rate for Payer: Medical Associates Commercial |
$0.80
|
| Rate for Payer: Midlands Choice Commercial |
$0.75
|
| Rate for Payer: United Healthcare Commercial |
$0.96
|
|
|
busPIRone 5 mg Tab
|
Facility
OP
|
$1.07
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701794
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of IA Commercial |
$0.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.96
|
| Rate for Payer: Aetna of IA Medicare |
$0.61
|
| Rate for Payer: Amerigroup Medicaid |
$0.54
|
| Rate for Payer: Amerigroup Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.53
|
| Rate for Payer: Medical Associates Commercial |
$0.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.54
|
| Rate for Payer: Midlands Choice Commercial |
$0.75
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$0.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.63
|
|
|
CA 125 DMCL
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
CPT 86304
|
| Hospital Charge Code |
8037505
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
|
|
CA 125 DMCL
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
CPT 86304
|
| Hospital Charge Code |
8037505
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Aetna of IA Medicare |
$96.90
|
| Rate for Payer: Amerigroup Medicaid |
$85.80
|
| Rate for Payer: Amerigroup Medicare |
$85.85
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$85.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$84.97
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$85.00
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$86.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$127.50
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.30
|
| Rate for Payer: Wellmark IA HMO |
$31.00
|
| Rate for Payer: Wellmark IA PPO |
$34.10
|
|
|
CA 15 3 DMCL
|
Facility
IP
|
$82.00
|
|
|
Service Code
|
CPT 86300
|
| Hospital Charge Code |
8519168
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
|
|
CA 15 3 DMCL
|
Facility
OP
|
$82.00
|
|
|
Service Code
|
CPT 86300
|
| Hospital Charge Code |
8519168
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Aetna of IA Medicare |
$46.74
|
| Rate for Payer: Amerigroup Medicaid |
$41.39
|
| Rate for Payer: Amerigroup Medicare |
$41.41
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$41.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40.98
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$41.00
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.50
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.38
|
| Rate for Payer: Wellmark IA HMO |
$31.00
|
| Rate for Payer: Wellmark IA PPO |
$34.10
|
|
|
CA 19 9 DMCL
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
8037506
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Aetna of IA Medicare |
$96.90
|
| Rate for Payer: Amerigroup Medicaid |
$85.80
|
| Rate for Payer: Amerigroup Medicare |
$85.85
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$85.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$84.97
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$85.00
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$86.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$127.50
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.30
|
| Rate for Payer: Wellmark IA HMO |
$31.00
|
| Rate for Payer: Wellmark IA PPO |
$34.10
|
|
|
CA 19 9 DMCL
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
8037506
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
|
|
CA 27.29 DMCL
|
Facility
OP
|
$82.00
|
|
|
Service Code
|
CPT 86300
|
| Hospital Charge Code |
8519159
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Aetna of IA Medicare |
$46.74
|
| Rate for Payer: Amerigroup Medicaid |
$41.39
|
| Rate for Payer: Amerigroup Medicare |
$41.41
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$41.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40.98
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$41.00
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.50
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.38
|
| Rate for Payer: Wellmark IA HMO |
$31.00
|
| Rate for Payer: Wellmark IA PPO |
$34.10
|
|
|
CA 27.29 DMCL
|
Facility
IP
|
$82.00
|
|
|
Service Code
|
CPT 86300
|
| Hospital Charge Code |
8519159
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of IA Commercial |
$73.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$73.80
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$61.50
|
| Rate for Payer: Medical Associates Commercial |
$61.50
|
| Rate for Payer: Midlands Choice Commercial |
$57.40
|
| Rate for Payer: United Healthcare Commercial |
$73.80
|
|
|
CABLE PLUGS FOR 4.0 MM LOCKING SCREWS
|
Facility
OP
|
$57.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Aetna of IA Commercial |
$51.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.30
|
| Rate for Payer: Aetna of IA Medicare |
$32.49
|
| Rate for Payer: Amerigroup Medicaid |
$28.77
|
| Rate for Payer: Amerigroup Medicare |
$28.78
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$28.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.49
|
| Rate for Payer: Medical Associates Commercial |
$42.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$28.50
|
| Rate for Payer: Midlands Choice Commercial |
$39.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$28.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.75
|
| Rate for Payer: United Healthcare Commercial |
$51.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$33.63
|
|
|
CABLE PLUGS FOR 4.0 MM LOCKING SCREWS
|
Facility
IP
|
$57.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8046631
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Aetna of IA Commercial |
$51.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$51.30
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$42.75
|
| Rate for Payer: Medical Associates Commercial |
$42.75
|
| Rate for Payer: Midlands Choice Commercial |
$39.90
|
| Rate for Payer: United Healthcare Commercial |
$51.30
|
|
|
CADEXOMER IODINE GEL 40G 11.4 OZ
|
Facility
IP
|
$126.00
|
|
|
Service Code
|
CPT A6261
|
| Hospital Charge Code |
8013712
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$113.40 |
| Rate for Payer: Aetna of IA Commercial |
$113.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$113.40
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$94.50
|
| Rate for Payer: Medical Associates Commercial |
$94.50
|
| Rate for Payer: Midlands Choice Commercial |
$88.20
|
| Rate for Payer: United Healthcare Commercial |
$113.40
|
|
|
CADEXOMER IODINE GEL 40G 11.4 OZ
|
Facility
OP
|
$126.00
|
|
|
Service Code
|
CPT A6261
|
| Hospital Charge Code |
8013712
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.97 |
| Max. Negotiated Rate |
$113.40 |
| Rate for Payer: Aetna of IA Commercial |
$113.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$113.40
|
| Rate for Payer: Aetna of IA Medicare |
$71.82
|
| Rate for Payer: Amerigroup Medicaid |
$63.59
|
| Rate for Payer: Amerigroup Medicare |
$63.63
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$94.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$63.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.97
|
| Rate for Payer: Medical Associates Commercial |
$94.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$63.00
|
| Rate for Payer: Midlands Choice Commercial |
$88.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$94.50
|
| Rate for Payer: United Healthcare Commercial |
$113.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$74.34
|
|
|
caffeine 200 mg Tab
|
Facility
OP
|
$1.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43718000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of IA Commercial |
$1.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.44
|
| Rate for Payer: Aetna of IA Medicare |
$0.91
|
| Rate for Payer: Amerigroup Medicaid |
$0.81
|
| Rate for Payer: Amerigroup Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.80
|
| Rate for Payer: Medical Associates Commercial |
$1.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.80
|
| Rate for Payer: Midlands Choice Commercial |
$1.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.94
|
|
|
caffeine 200 mg Tab
|
Facility
IP
|
$1.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43718000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of IA Commercial |
$1.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.44
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.20
|
| Rate for Payer: Medical Associates Commercial |
$1.20
|
| Rate for Payer: Midlands Choice Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
|
|
caffeine citrated soln 60mg/3ml SDV
|
Facility
OP
|
$107.84
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
43750237
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$97.06 |
| Rate for Payer: Aetna of IA Commercial |
$97.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.06
|
| Rate for Payer: Aetna of IA Medicare |
$61.47
|
| Rate for Payer: Amerigroup Medicaid |
$54.43
|
| Rate for Payer: Amerigroup Medicare |
$54.46
|
| Rate for Payer: Cash Price |
$86.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$53.90
|
| Rate for Payer: Medical Associates Commercial |
$80.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.92
|
| Rate for Payer: Midlands Choice Commercial |
$75.49
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$80.88
|
| Rate for Payer: United Healthcare Commercial |
$97.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.63
|
|
|
caffeine citrated soln 60mg/3ml SDV
|
Facility
IP
|
$107.84
|
|
|
Service Code
|
CPT J0706
|
| Hospital Charge Code |
43750237
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.49 |
| Max. Negotiated Rate |
$97.06 |
| Rate for Payer: Aetna of IA Commercial |
$97.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.06
|
| Rate for Payer: Cash Price |
$86.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.88
|
| Rate for Payer: Medical Associates Commercial |
$80.88
|
| Rate for Payer: Midlands Choice Commercial |
$75.49
|
| Rate for Payer: United Healthcare Commercial |
$97.06
|
|
|
calamine-zinc oxide Top 8% susp
|
Facility
IP
|
$9.92
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.94 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna of IA Commercial |
$8.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.93
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.44
|
| Rate for Payer: Medical Associates Commercial |
$7.44
|
| Rate for Payer: Midlands Choice Commercial |
$6.94
|
| Rate for Payer: United Healthcare Commercial |
$8.93
|
|
|
calamine-zinc oxide Top 8% susp
|
Facility
OP
|
$9.92
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna of IA Commercial |
$8.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.93
|
| Rate for Payer: Aetna of IA Medicare |
$5.65
|
| Rate for Payer: Amerigroup Medicaid |
$5.01
|
| Rate for Payer: Amerigroup Medicare |
$5.01
|
| Rate for Payer: Cash Price |
$7.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.96
|
| Rate for Payer: Medical Associates Commercial |
$7.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.96
|
| Rate for Payer: Midlands Choice Commercial |
$6.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.44
|
| Rate for Payer: United Healthcare Commercial |
$8.93
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.85
|
|
