|
citalopram 20 mg Tab
|
Facility
IP
|
$1.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of IA Commercial |
$1.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.05
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
|
|
citalopram 20 mg Tab
|
Facility
OP
|
$1.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of IA Commercial |
$1.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.05
|
| Rate for Payer: Aetna of IA Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicaid |
$0.59
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.58
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.69
|
|
|
CK
|
Facility
OP
|
$71.00
|
|
|
Service Code
|
CPT 82550
|
| Hospital Charge Code |
4010788
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$63.90 |
| Rate for Payer: Aetna of IA Commercial |
$63.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.90
|
| Rate for Payer: Aetna of IA Medicare |
$40.47
|
| Rate for Payer: Amerigroup Medicaid |
$35.83
|
| Rate for Payer: Amerigroup Medicare |
$35.86
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$35.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.49
|
| Rate for Payer: Medical Associates Commercial |
$53.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$35.50
|
| Rate for Payer: Midlands Choice Commercial |
$49.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$53.25
|
| Rate for Payer: United Healthcare Commercial |
$63.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$41.89
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
CK
|
Facility
IP
|
$71.00
|
|
|
Service Code
|
CPT 82550
|
| Hospital Charge Code |
4010788
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.70 |
| Max. Negotiated Rate |
$63.90 |
| Rate for Payer: Aetna of IA Commercial |
$63.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.90
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.25
|
| Rate for Payer: Medical Associates Commercial |
$53.25
|
| Rate for Payer: Midlands Choice Commercial |
$49.70
|
| Rate for Payer: United Healthcare Commercial |
$63.90
|
|
|
CKMB
|
Facility
IP
|
$139.00
|
|
|
Service Code
|
CPT 82553
|
| Hospital Charge Code |
8093949
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
|
|
CKMB
|
Facility
OP
|
$139.00
|
|
|
Service Code
|
CPT 82553
|
| Hospital Charge Code |
8093949
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Aetna of IA Medicare |
$79.23
|
| Rate for Payer: Amerigroup Medicaid |
$70.15
|
| Rate for Payer: Amerigroup Medicare |
$70.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$69.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.47
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$69.50
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$104.25
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.01
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
CKMB and Index DMCL
|
Facility
OP
|
$139.00
|
|
|
Service Code
|
CPT 82553
|
| Hospital Charge Code |
8037513
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Aetna of IA Medicare |
$79.23
|
| Rate for Payer: Amerigroup Medicaid |
$70.15
|
| Rate for Payer: Amerigroup Medicare |
$70.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$69.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.47
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$69.50
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$104.25
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.01
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
CKMB and Index DMCL
|
Facility
IP
|
$139.00
|
|
|
Service Code
|
CPT 82553
|
| Hospital Charge Code |
8037513
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
|
|
CK MB DMCL
|
Facility
IP
|
$71.00
|
|
|
Service Code
|
CPT 82550
|
| Hospital Charge Code |
8037511
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.70 |
| Max. Negotiated Rate |
$63.90 |
| Rate for Payer: Aetna of IA Commercial |
$63.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.90
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.25
|
| Rate for Payer: Medical Associates Commercial |
$53.25
|
| Rate for Payer: Midlands Choice Commercial |
$49.70
|
| Rate for Payer: United Healthcare Commercial |
$63.90
|
|
|
CK MB DMCL
|
Facility
OP
|
$71.00
|
|
|
Service Code
|
CPT 82550
|
| Hospital Charge Code |
8037511
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$63.90 |
| Rate for Payer: Aetna of IA Commercial |
$63.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.90
|
| Rate for Payer: Aetna of IA Medicare |
$40.47
|
| Rate for Payer: Amerigroup Medicaid |
$35.83
|
| Rate for Payer: Amerigroup Medicare |
$35.86
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$35.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.49
|
| Rate for Payer: Medical Associates Commercial |
$53.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$35.50
|
| Rate for Payer: Midlands Choice Commercial |
$49.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$53.25
|
| Rate for Payer: United Healthcare Commercial |
$63.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$41.89
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
CK Total DMCL
|
Facility
IP
|
$71.00
|
|
|
Service Code
|
CPT 82550
|
| Hospital Charge Code |
8037512
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.70 |
| Max. Negotiated Rate |
$63.90 |
| Rate for Payer: Aetna of IA Commercial |
$63.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.90
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.25
|
| Rate for Payer: Medical Associates Commercial |
$53.25
|
| Rate for Payer: Midlands Choice Commercial |
$49.70
|
| Rate for Payer: United Healthcare Commercial |
$63.90
|
|
|
CK Total DMCL
|
Facility
OP
|
$71.00
|
|
|
Service Code
|
CPT 82550
|
| Hospital Charge Code |
8037512
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$63.90 |
| Rate for Payer: Aetna of IA Commercial |
$63.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$63.90
|
| Rate for Payer: Aetna of IA Medicare |
$40.47
|
| Rate for Payer: Amerigroup Medicaid |
$35.83
|
| Rate for Payer: Amerigroup Medicare |
$35.86
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Cash Price |
$56.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$53.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$35.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$35.49
|
| Rate for Payer: Medical Associates Commercial |
$53.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$35.50
|
| Rate for Payer: Midlands Choice Commercial |
$49.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$53.25
|
| Rate for Payer: United Healthcare Commercial |
$63.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$41.89
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
clindamycin 150 mg Cap
|
Facility
IP
|
$1.86
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Aetna of IA Commercial |
$1.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.67
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.40
|
| Rate for Payer: Medical Associates Commercial |
$1.40
|
| Rate for Payer: Midlands Choice Commercial |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.67
|
|
|
clindamycin 150 mg Cap
|
Facility
OP
|
$1.86
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Aetna of IA Commercial |
$1.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.67
|
| Rate for Payer: Aetna of IA Medicare |
$1.06
|
| Rate for Payer: Amerigroup Medicaid |
$0.94
|
| Rate for Payer: Amerigroup Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.40
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.93
|
| Rate for Payer: Medical Associates Commercial |
$1.40
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.93
|
| Rate for Payer: Midlands Choice Commercial |
$1.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.67
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.10
|
|
|
clindamycin 300 mg/50 mL-D5W IV SDV
|
Facility
IP
|
$76.05
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43791288
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.24 |
| Max. Negotiated Rate |
$68.44 |
| Rate for Payer: Aetna of IA Commercial |
$68.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.44
|
| Rate for Payer: Cash Price |
$60.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.04
|
| Rate for Payer: Medical Associates Commercial |
$57.04
|
| Rate for Payer: Midlands Choice Commercial |
$53.24
|
| Rate for Payer: United Healthcare Commercial |
$68.44
|
|
|
clindamycin 300 mg/50 mL-D5W IV SDV
|
Facility
OP
|
$76.05
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43791288
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$68.44 |
| Rate for Payer: Aetna of IA Commercial |
$68.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.44
|
| Rate for Payer: Aetna of IA Medicare |
$43.35
|
| Rate for Payer: Amerigroup Medicaid |
$38.38
|
| Rate for Payer: Amerigroup Medicare |
$38.41
|
| Rate for Payer: Cash Price |
$60.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.04
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$38.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.01
|
| Rate for Payer: Medical Associates Commercial |
$57.04
|
| Rate for Payer: Medical Associates Managed Medicare |
$38.02
|
| Rate for Payer: Midlands Choice Commercial |
$53.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.04
|
| Rate for Payer: United Healthcare Commercial |
$68.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$44.87
|
|
|
clindamycin 600 mg/50 mL-D5W IV SDV
|
Facility
IP
|
$66.38
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43733750
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.47 |
| Max. Negotiated Rate |
$59.74 |
| Rate for Payer: Aetna of IA Commercial |
$59.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.74
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.78
|
| Rate for Payer: Medical Associates Commercial |
$49.78
|
| Rate for Payer: Midlands Choice Commercial |
$46.47
|
| Rate for Payer: United Healthcare Commercial |
$59.74
|
|
|
clindamycin 600 mg/50 mL-D5W IV SDV
|
Facility
OP
|
$66.38
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43733750
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.18 |
| Max. Negotiated Rate |
$59.74 |
| Rate for Payer: Aetna of IA Commercial |
$59.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.74
|
| Rate for Payer: Aetna of IA Medicare |
$37.84
|
| Rate for Payer: Amerigroup Medicaid |
$33.50
|
| Rate for Payer: Amerigroup Medicare |
$33.52
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$33.19
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.18
|
| Rate for Payer: Medical Associates Commercial |
$49.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.19
|
| Rate for Payer: Midlands Choice Commercial |
$46.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$49.78
|
| Rate for Payer: United Healthcare Commercial |
$59.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.16
|
|
|
clindamycin 900 mg/50 mL-D5W IV SDV
|
Facility
OP
|
$98.02
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.99 |
| Max. Negotiated Rate |
$88.22 |
| Rate for Payer: Aetna of IA Commercial |
$88.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.22
|
| Rate for Payer: Aetna of IA Medicare |
$55.87
|
| Rate for Payer: Amerigroup Medicaid |
$49.47
|
| Rate for Payer: Amerigroup Medicare |
$49.50
|
| Rate for Payer: Cash Price |
$78.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$73.52
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$48.99
|
| Rate for Payer: Medical Associates Commercial |
$73.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.01
|
| Rate for Payer: Midlands Choice Commercial |
$68.61
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$49.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$73.52
|
| Rate for Payer: United Healthcare Commercial |
$88.22
|
| Rate for Payer: United Healthcare Managed Medicare |
$57.83
|
|
|
clindamycin 900 mg/50 mL-D5W IV SDV
|
Facility
IP
|
$98.02
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.61 |
| Max. Negotiated Rate |
$88.22 |
| Rate for Payer: Aetna of IA Commercial |
$88.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$88.22
|
| Rate for Payer: Cash Price |
$78.41
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$73.52
|
| Rate for Payer: Medical Associates Commercial |
$73.52
|
| Rate for Payer: Midlands Choice Commercial |
$68.61
|
| Rate for Payer: United Healthcare Commercial |
$88.22
|
|
|
clobetasol propionate topical 0.05% Sol 50ml
|
Facility
IP
|
$108.00
|
|
|
Service Code
|
CPT DE200
|
| Hospital Charge Code |
43700502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna of IA Commercial |
$97.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.20
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.00
|
| Rate for Payer: Medical Associates Commercial |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$75.60
|
| Rate for Payer: United Healthcare Commercial |
$97.20
|
|
|
clobetasol propionate topical 0.05% Sol 50ml
|
Facility
OP
|
$108.00
|
|
|
Service Code
|
CPT DE200
|
| Hospital Charge Code |
43700502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.98 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna of IA Commercial |
$97.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.20
|
| Rate for Payer: Aetna of IA Medicare |
$61.56
|
| Rate for Payer: Amerigroup Medicaid |
$54.51
|
| Rate for Payer: Amerigroup Medicare |
$54.54
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$53.98
|
| Rate for Payer: Medical Associates Commercial |
$81.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.00
|
| Rate for Payer: Midlands Choice Commercial |
$75.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.00
|
| Rate for Payer: United Healthcare Commercial |
$97.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.72
|
|
|
clonazePAM 0.25 mg Dis Tab
|
Facility
IP
|
$4.53
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43792316
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna of IA Commercial |
$4.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.08
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.40
|
| Rate for Payer: Medical Associates Commercial |
$3.40
|
| Rate for Payer: Midlands Choice Commercial |
$3.17
|
| Rate for Payer: United Healthcare Commercial |
$4.08
|
|
|
clonazePAM 0.25 mg Dis Tab
|
Facility
OP
|
$4.53
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43792316
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna of IA Commercial |
$4.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.08
|
| Rate for Payer: Aetna of IA Medicare |
$2.58
|
| Rate for Payer: Amerigroup Medicaid |
$2.29
|
| Rate for Payer: Amerigroup Medicare |
$2.29
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.40
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.26
|
| Rate for Payer: Medical Associates Commercial |
$3.40
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.26
|
| Rate for Payer: Midlands Choice Commercial |
$3.17
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$4.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.67
|
|
|
clonazePAM 0.5 mg Tab
|
Facility
OP
|
$3.11
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701046
|
|
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
|
|
