|
diclofenac Top 1% gel
|
Facility
IP
|
$18.02
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.61 |
| Max. Negotiated Rate |
$16.22 |
| Rate for Payer: Aetna of IA Commercial |
$16.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.22
|
| Rate for Payer: Cash Price |
$14.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.52
|
| Rate for Payer: Medical Associates Commercial |
$13.52
|
| Rate for Payer: Midlands Choice Commercial |
$12.61
|
| Rate for Payer: United Healthcare Commercial |
$16.22
|
|
|
diclofenac Top 1% gel
|
Facility
OP
|
$18.02
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.01 |
| Max. Negotiated Rate |
$16.22 |
| Rate for Payer: Aetna of IA Commercial |
$16.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.22
|
| Rate for Payer: Aetna of IA Medicare |
$10.27
|
| Rate for Payer: Amerigroup Medicaid |
$9.09
|
| Rate for Payer: Amerigroup Medicare |
$9.10
|
| Rate for Payer: Cash Price |
$14.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.52
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.01
|
| Rate for Payer: Medical Associates Commercial |
$13.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.01
|
| Rate for Payer: Midlands Choice Commercial |
$12.61
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.52
|
| Rate for Payer: United Healthcare Commercial |
$16.22
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.63
|
|
|
dicyclomine 20 mg Tab
|
Facility
IP
|
$1.44
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43741282
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| 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 |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
|
|
dicyclomine 20 mg Tab
|
Facility
OP
|
$1.44
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43741282
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.72 |
| 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: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.73
|
| Rate for Payer: Amerigroup Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.72
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.72
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
|
Digestive Malignancy With CC
|
Facility
IP
|
$10,539.26
|
|
|
Service Code
|
MS-DRG 375
|
| Hospital Charge Code |
216
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$10,539.26 |
| Rate for Payer: Amerigroup Medicaid |
$10,488.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10,386.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,539.26
|
|
|
Digestive Malignancy With MCC
|
Facility
IP
|
$15,882.71
|
|
|
Service Code
|
MS-DRG 374
|
| Hospital Charge Code |
215
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$15,882.71 |
| Rate for Payer: Amerigroup Medicaid |
$15,805.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15,652.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15,882.71
|
|
|
Digestive Malignancy Without CC/MCC
|
Facility
IP
|
$7,011.73
|
|
|
Service Code
|
MS-DRG 376
|
| Hospital Charge Code |
217
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,011.73 |
| Rate for Payer: Amerigroup Medicaid |
$6,977.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,910.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,011.73
|
|
|
DIGIT AMPUTATION ER CHARGE
|
Professional
|
$2,327.00
|
|
| Hospital Charge Code |
8069104
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$1,628.90 |
| Rate for Payer: Cash Price |
$1,861.60
|
| Rate for Payer: Cash Price |
$1,861.60
|
| Rate for Payer: Medical Associates Commercial |
$75.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,628.90
|
|
|
DIGOXIN
|
Facility
OP
|
$111.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
1628891
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Aetna of IA Medicare |
$63.27
|
| Rate for Payer: Amerigroup Medicaid |
$56.02
|
| Rate for Payer: Amerigroup Medicare |
$56.06
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.48
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.25
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.49
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
DIGOXIN
|
Facility
IP
|
$111.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
1628891
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
|
|
digoxin 125 mcg (0.125 mg) Tab
|
Facility
OP
|
$2.31
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna of IA Commercial |
$2.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.08
|
| Rate for Payer: Aetna of IA Medicare |
$1.32
|
| Rate for Payer: Amerigroup Medicaid |
$1.17
|
| Rate for Payer: Amerigroup Medicare |
$1.17
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.73
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.15
|
| Rate for Payer: Medical Associates Commercial |
$1.73
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.16
|
| Rate for Payer: Midlands Choice Commercial |
$1.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.73
|
| Rate for Payer: United Healthcare Commercial |
$2.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.36
|
|
|
digoxin 125 mcg (0.125 mg) Tab
|
Facility
IP
|
$2.31
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: Aetna of IA Commercial |
$2.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.08
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.73
|
| Rate for Payer: Medical Associates Commercial |
$1.73
|
| Rate for Payer: Midlands Choice Commercial |
$1.62
|
| Rate for Payer: United Healthcare Commercial |
$2.08
|
|
|
digoxin 250 mcg (0.25 mg) Tab
|
Facility
IP
|
$2.50
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701722
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Aetna of IA Commercial |
$2.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.25
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.88
|
| Rate for Payer: Medical Associates Commercial |
$1.88
|
| Rate for Payer: Midlands Choice Commercial |
$1.75
|
| Rate for Payer: United Healthcare Commercial |
$2.25
|
|
|
digoxin 250 mcg (0.25 mg) Tab
|
Facility
OP
|
$2.50
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701722
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Aetna of IA Commercial |
$2.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.25
|
| Rate for Payer: Aetna of IA Medicare |
$1.42
|
| Rate for Payer: Amerigroup Medicaid |
$1.26
|
| Rate for Payer: Amerigroup Medicare |
$1.26
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.25
|
| Rate for Payer: Medical Associates Commercial |
$1.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.25
|
| Rate for Payer: Midlands Choice Commercial |
$1.75
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.88
|
| Rate for Payer: United Healthcare Commercial |
$2.25
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.48
|
|
|
digoxin 250 mcg/mL (0.25 mg/mL) 2 ML SDV Inj Sol
|
Facility
OP
|
$32.22
|
|
|
Service Code
|
CPT J1160
|
| Hospital Charge Code |
43725025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna of IA Commercial |
$29.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.00
|
| Rate for Payer: Aetna of IA Medicare |
$18.37
|
| Rate for Payer: Amerigroup Medicaid |
$16.26
|
| Rate for Payer: Amerigroup Medicare |
$16.27
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$16.11
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.10
|
| Rate for Payer: Medical Associates Commercial |
$24.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.11
|
| Rate for Payer: Midlands Choice Commercial |
$22.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.16
|
| Rate for Payer: United Healthcare Commercial |
$29.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.01
|
|
|
digoxin 250 mcg/mL (0.25 mg/mL) 2 ML SDV Inj Sol
|
Facility
IP
|
$32.22
|
|
|
Service Code
|
CPT J1160
|
| Hospital Charge Code |
43725025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.55 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: Aetna of IA Commercial |
$29.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.00
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.16
|
| Rate for Payer: Medical Associates Commercial |
$24.16
|
| Rate for Payer: Midlands Choice Commercial |
$22.55
|
| Rate for Payer: United Healthcare Commercial |
$29.00
|
|
|
digoxin 50 mcg/mL 60 ml oral sol (0.05 mg/mL)
|
Facility
OP
|
$358.16
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.01 |
| Max. Negotiated Rate |
$322.34 |
| Rate for Payer: Aetna of IA Commercial |
$322.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$322.34
|
| Rate for Payer: Aetna of IA Medicare |
$204.15
|
| Rate for Payer: Amerigroup Medicaid |
$180.76
|
| Rate for Payer: Amerigroup Medicare |
$180.87
|
| Rate for Payer: Cash Price |
$286.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$268.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$179.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$179.01
|
| Rate for Payer: Medical Associates Commercial |
$268.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$179.08
|
| Rate for Payer: Midlands Choice Commercial |
$250.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$181.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$268.62
|
| Rate for Payer: United Healthcare Commercial |
$322.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$211.31
|
|
|
digoxin 50 mcg/mL 60 ml oral sol (0.05 mg/mL)
|
Facility
IP
|
$358.16
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$250.71 |
| Max. Negotiated Rate |
$322.34 |
| Rate for Payer: Aetna of IA Commercial |
$322.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$322.34
|
| Rate for Payer: Cash Price |
$286.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$268.62
|
| Rate for Payer: Medical Associates Commercial |
$268.62
|
| Rate for Payer: Midlands Choice Commercial |
$250.71
|
| Rate for Payer: United Healthcare Commercial |
$322.34
|
|
|
digoxin immune FAB 40 mg Inj SDV
|
Facility
OP
|
$8,236.48
|
|
|
Service Code
|
CPT J1162
|
| Hospital Charge Code |
43701718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,116.59 |
| Max. Negotiated Rate |
$7,412.83 |
| Rate for Payer: Aetna of IA Commercial |
$7,412.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,412.83
|
| Rate for Payer: Aetna of IA Medicare |
$4,694.79
|
| Rate for Payer: Amerigroup Medicaid |
$4,156.95
|
| Rate for Payer: Amerigroup Medicare |
$4,159.42
|
| Rate for Payer: Cash Price |
$6,589.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,177.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4,118.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,116.59
|
| Rate for Payer: Medical Associates Commercial |
$6,177.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$4,118.24
|
| Rate for Payer: Midlands Choice Commercial |
$5,765.54
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,180.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$6,177.36
|
| Rate for Payer: United Healthcare Commercial |
$7,412.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$4,859.52
|
|
|
digoxin immune FAB 40 mg Inj SDV
|
Facility
IP
|
$8,236.48
|
|
|
Service Code
|
CPT J1162
|
| Hospital Charge Code |
43701718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,765.54 |
| Max. Negotiated Rate |
$7,412.83 |
| Rate for Payer: Aetna of IA Commercial |
$7,412.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7,412.83
|
| Rate for Payer: Cash Price |
$6,589.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6,177.36
|
| Rate for Payer: Medical Associates Commercial |
$6,177.36
|
| Rate for Payer: Midlands Choice Commercial |
$5,765.54
|
| Rate for Payer: United Healthcare Commercial |
$7,412.83
|
|
|
DILANTIN (PHENYTOIN)
|
Facility
OP
|
$111.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
8093930
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Aetna of IA Medicare |
$63.27
|
| Rate for Payer: Amerigroup Medicaid |
$56.02
|
| Rate for Payer: Amerigroup Medicare |
$56.06
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.48
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.25
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.49
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
DILANTIN (PHENYTOIN)
|
Facility
IP
|
$111.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
8093930
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
|
|
diltiazem 120 mg/24 hours ERCap
|
Facility
OP
|
$2.18
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701804
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna of IA Commercial |
$1.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.96
|
| Rate for Payer: Aetna of IA Medicare |
$1.24
|
| Rate for Payer: Amerigroup Medicaid |
$1.10
|
| Rate for Payer: Amerigroup Medicare |
$1.10
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.09
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.09
|
| Rate for Payer: Medical Associates Commercial |
$1.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.09
|
| Rate for Payer: Midlands Choice Commercial |
$1.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.64
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.29
|
|
|
diltiazem 120 mg/24 hours ERCap
|
Facility
IP
|
$2.18
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701804
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Aetna of IA Commercial |
$1.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.96
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.64
|
| Rate for Payer: Medical Associates Commercial |
$1.64
|
| Rate for Payer: Midlands Choice Commercial |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
|
|
diltiazem 180 mg/24 hours ERCap
|
Facility
OP
|
$1.87
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43795213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Aetna of IA Commercial |
$1.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.68
|
| Rate for Payer: Aetna of IA Medicare |
$1.07
|
| 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 |
$0.94
|
| 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 |
$0.94
|
| Rate for Payer: Midlands Choice Commercial |
$1.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.10
|
|
