|
diltiazem 180 mg/24 hours ERCap
|
Facility
IP
|
$1.87
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43795213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| 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: 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 |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.68
|
|
|
diltiazem 30 mg Tab
|
Facility
IP
|
$2.11
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Midlands Choice Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
|
|
diltiazem 30 mg Tab
|
Facility
OP
|
$2.11
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Aetna of IA Medicare |
$1.20
|
| Rate for Payer: Amerigroup Medicaid |
$1.06
|
| Rate for Payer: Amerigroup Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.05
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.06
|
| Rate for Payer: Midlands Choice Commercial |
$1.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.24
|
|
|
dilTIAZem 5 mg/mL 5ml vial SOL SDV
|
Facility
OP
|
$31.11
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.55 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna of IA Commercial |
$28.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.00
|
| Rate for Payer: Aetna of IA Medicare |
$17.73
|
| Rate for Payer: Amerigroup Medicaid |
$15.70
|
| Rate for Payer: Amerigroup Medicare |
$15.71
|
| Rate for Payer: Cash Price |
$24.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.33
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.55
|
| Rate for Payer: Medical Associates Commercial |
$23.33
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.56
|
| Rate for Payer: Midlands Choice Commercial |
$21.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.33
|
| Rate for Payer: United Healthcare Commercial |
$28.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.35
|
|
|
dilTIAZem 5 mg/mL 5ml vial SOL SDV
|
Facility
IP
|
$31.11
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.78 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna of IA Commercial |
$28.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.00
|
| Rate for Payer: Cash Price |
$24.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.33
|
| Rate for Payer: Medical Associates Commercial |
$23.33
|
| Rate for Payer: Midlands Choice Commercial |
$21.78
|
| Rate for Payer: United Healthcare Commercial |
$28.00
|
|
|
diphenhydrAMINE 12.5 mg/5 mL 10 ml Oral Liq
|
Facility
OP
|
$7.59
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43712028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Aetna of IA Commercial |
$6.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.83
|
| Rate for Payer: Aetna of IA Medicare |
$4.33
|
| Rate for Payer: Amerigroup Medicaid |
$3.83
|
| Rate for Payer: Amerigroup Medicare |
$3.83
|
| Rate for Payer: Cash Price |
$6.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.79
|
| Rate for Payer: Medical Associates Commercial |
$5.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.80
|
| Rate for Payer: Midlands Choice Commercial |
$5.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.69
|
| Rate for Payer: United Healthcare Commercial |
$6.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.48
|
|
|
diphenhydrAMINE 12.5 mg/5 mL 10 ml Oral Liq
|
Facility
IP
|
$7.59
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43712028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Aetna of IA Commercial |
$6.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.83
|
| Rate for Payer: Cash Price |
$6.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.69
|
| Rate for Payer: Medical Associates Commercial |
$5.69
|
| Rate for Payer: Midlands Choice Commercial |
$5.31
|
| Rate for Payer: United Healthcare Commercial |
$6.83
|
|
|
diphenhydrAMINE 25 mg Cap
|
Facility
OP
|
$1.13
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700041
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Aetna of IA Medicare |
$0.64
|
| Rate for Payer: Amerigroup Medicaid |
$0.57
|
| Rate for Payer: Amerigroup Medicare |
$0.57
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.56
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.57
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.67
|
|
|
diphenhydrAMINE 25 mg Cap
|
Facility
IP
|
$1.13
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700041
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of IA Commercial |
$1.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.02
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.85
|
| Rate for Payer: Medical Associates Commercial |
$0.85
|
| Rate for Payer: Midlands Choice Commercial |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$1.02
|
|
|
diphenhydrAMINE 50 mg Cap
|
Facility
OP
|
$1.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702360
|
|
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
|
|
|
diphenhydrAMINE 50 mg Cap
|
Facility
IP
|
$1.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702360
|
|
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
|
|
|
diphenhydrAMINE 50 mg/mL 1ml SDV Inj [VDMC]
|
Facility
IP
|
$24.31
|
|
|
Service Code
|
CPT J1200
|
| Hospital Charge Code |
43702278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.02 |
| Max. Negotiated Rate |
$21.88 |
| Rate for Payer: Aetna of IA Commercial |
$21.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.88
|
| Rate for Payer: Cash Price |
$19.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.23
|
| Rate for Payer: Medical Associates Commercial |
$18.23
|
| Rate for Payer: Midlands Choice Commercial |
$17.02
|
| Rate for Payer: United Healthcare Commercial |
$21.88
|
|
|
diphenhydrAMINE 50 mg/mL 1ml SDV Inj [VDMC]
|
Facility
OP
|
$24.31
|
|
|
Service Code
|
CPT J1200
|
| Hospital Charge Code |
43702278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$21.88 |
| Rate for Payer: Aetna of IA Commercial |
$21.88
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.88
|
| Rate for Payer: Aetna of IA Medicare |
$13.86
|
| Rate for Payer: Amerigroup Medicaid |
$12.27
|
| Rate for Payer: Amerigroup Medicare |
$12.28
|
| Rate for Payer: Cash Price |
$19.45
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.23
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.15
|
| Rate for Payer: Medical Associates Commercial |
$18.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.16
|
| Rate for Payer: Midlands Choice Commercial |
$17.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.23
|
| Rate for Payer: United Healthcare Commercial |
$21.88
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.34
|
|
|
diphtheria/hepB/pertussis,acel/polio/tetanus - Sus SDV
|
Facility
IP
|
$142.14
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
43700440
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.50 |
| Max. Negotiated Rate |
$127.93 |
| Rate for Payer: Aetna of IA Commercial |
$127.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.93
|
| Rate for Payer: Cash Price |
$113.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.60
|
| Rate for Payer: Medical Associates Commercial |
$106.60
|
| Rate for Payer: Midlands Choice Commercial |
$99.50
|
| Rate for Payer: United Healthcare Commercial |
$127.93
|
|
|
diphtheria/hepB/pertussis,acel/polio/tetanus - Sus SDV
|
Facility
OP
|
$142.14
|
|
|
Service Code
|
CPT 90723
|
| Hospital Charge Code |
43700440
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.00 |
| Max. Negotiated Rate |
$127.93 |
| Rate for Payer: Aetna of IA Commercial |
$127.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.93
|
| Rate for Payer: Aetna of IA Medicare |
$81.02
|
| Rate for Payer: Amerigroup Medicaid |
$71.74
|
| Rate for Payer: Amerigroup Medicare |
$71.78
|
| Rate for Payer: Cash Price |
$113.71
|
| Rate for Payer: Cash Price |
$113.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$71.07
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$71.04
|
| Rate for Payer: Medical Associates Commercial |
$106.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$71.07
|
| Rate for Payer: Midlands Choice Commercial |
$99.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$72.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$106.60
|
| Rate for Payer: United Healthcare Commercial |
$127.93
|
| Rate for Payer: United Healthcare Managed Medicare |
$83.86
|
| Rate for Payer: Wellmark IA HMO |
$62.00
|
| Rate for Payer: Wellmark IA PPO |
$68.20
|
|
|
diphtheria/pertussis,acel/tetanus/polio - Sus SDV
|
Facility
OP
|
$107.15
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
43700444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$96.44 |
| Rate for Payer: Aetna of IA Commercial |
$96.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$96.44
|
| Rate for Payer: Aetna of IA Medicare |
$61.08
|
| Rate for Payer: Amerigroup Medicaid |
$54.08
|
| Rate for Payer: Amerigroup Medicare |
$54.11
|
| Rate for Payer: Cash Price |
$85.72
|
| Rate for Payer: Cash Price |
$85.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$53.55
|
| Rate for Payer: Medical Associates Commercial |
$80.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.58
|
| Rate for Payer: Midlands Choice Commercial |
$75.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$54.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$80.36
|
| Rate for Payer: United Healthcare Commercial |
$96.44
|
| Rate for Payer: United Healthcare Managed Medicare |
$63.22
|
| Rate for Payer: Wellmark IA HMO |
$62.00
|
| Rate for Payer: Wellmark IA PPO |
$68.20
|
|
|
diphtheria/pertussis,acel/tetanus/polio - Sus SDV
|
Facility
IP
|
$107.15
|
|
|
Service Code
|
CPT 90696
|
| Hospital Charge Code |
43700444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$96.44 |
| Rate for Payer: Aetna of IA Commercial |
$96.44
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$96.44
|
| Rate for Payer: Cash Price |
$85.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$80.36
|
| Rate for Payer: Medical Associates Commercial |
$80.36
|
| Rate for Payer: Midlands Choice Commercial |
$75.00
|
| Rate for Payer: United Healthcare Commercial |
$96.44
|
|
|
diphtheria/tetanus/pertussis (DTaP) ped 25 units-10 units-58 mcg/0.5 mL Sus UD
|
Facility
IP
|
$61.30
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
43702480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.91 |
| Max. Negotiated Rate |
$55.17 |
| Rate for Payer: Aetna of IA Commercial |
$55.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.17
|
| Rate for Payer: Cash Price |
$49.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.98
|
| Rate for Payer: Medical Associates Commercial |
$45.98
|
| Rate for Payer: Midlands Choice Commercial |
$42.91
|
| Rate for Payer: United Healthcare Commercial |
$55.17
|
|
|
diphtheria/tetanus/pertussis (DTaP) ped 25 units-10 units-58 mcg/0.5 mL Sus UD
|
Facility
OP
|
$61.30
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
43702480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.64 |
| Max. Negotiated Rate |
$68.20 |
| Rate for Payer: Aetna of IA Commercial |
$55.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$55.17
|
| Rate for Payer: Aetna of IA Medicare |
$34.94
|
| Rate for Payer: Amerigroup Medicaid |
$30.94
|
| Rate for Payer: Amerigroup Medicare |
$30.96
|
| Rate for Payer: Cash Price |
$49.04
|
| Rate for Payer: Cash Price |
$49.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.64
|
| Rate for Payer: Medical Associates Commercial |
$45.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.65
|
| Rate for Payer: Midlands Choice Commercial |
$42.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.98
|
| Rate for Payer: United Healthcare Commercial |
$55.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$36.17
|
| Rate for Payer: Wellmark IA HMO |
$62.00
|
| Rate for Payer: Wellmark IA PPO |
$68.20
|
|
|
diphth/haemophilus/pertussis/tetanus/polio SDV
|
Facility
OP
|
$128.26
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
43700468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.00 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Aetna of IA Commercial |
$115.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$115.43
|
| Rate for Payer: Aetna of IA Medicare |
$73.11
|
| Rate for Payer: Amerigroup Medicaid |
$64.73
|
| Rate for Payer: Amerigroup Medicare |
$64.77
|
| Rate for Payer: Cash Price |
$102.61
|
| Rate for Payer: Cash Price |
$102.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.13
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$64.10
|
| Rate for Payer: Medical Associates Commercial |
$96.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$64.13
|
| Rate for Payer: Midlands Choice Commercial |
$89.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$65.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$96.20
|
| Rate for Payer: United Healthcare Commercial |
$115.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$75.67
|
| Rate for Payer: Wellmark IA HMO |
$62.00
|
| Rate for Payer: Wellmark IA PPO |
$68.20
|
|
|
diphth/haemophilus/pertussis/tetanus/polio SDV
|
Facility
IP
|
$128.26
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
43700468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.78 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Aetna of IA Commercial |
$115.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$115.43
|
| Rate for Payer: Cash Price |
$102.61
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.20
|
| Rate for Payer: Medical Associates Commercial |
$96.20
|
| Rate for Payer: Midlands Choice Commercial |
$89.78
|
| Rate for Payer: United Healthcare Commercial |
$115.43
|
|
|
dipyridamole 25 mg Tab
|
Facility
IP
|
$7.35
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702494
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna of IA Commercial |
$6.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.62
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.51
|
| Rate for Payer: Medical Associates Commercial |
$5.51
|
| Rate for Payer: Midlands Choice Commercial |
$5.14
|
| Rate for Payer: United Healthcare Commercial |
$6.62
|
|
|
dipyridamole 25 mg Tab
|
Facility
OP
|
$7.35
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702494
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna of IA Commercial |
$6.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$6.62
|
| Rate for Payer: Aetna of IA Medicare |
$4.19
|
| Rate for Payer: Amerigroup Medicaid |
$3.71
|
| Rate for Payer: Amerigroup Medicare |
$3.71
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$5.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.67
|
| Rate for Payer: Medical Associates Commercial |
$5.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.68
|
| Rate for Payer: Midlands Choice Commercial |
$5.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.51
|
| Rate for Payer: United Healthcare Commercial |
$6.62
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.34
|
|
|
dipyridamole 5 mg/mL 10 ml IV SDV [VDMC]
|
Facility
OP
|
$87.82
|
|
|
Service Code
|
CPT J1245
|
| Hospital Charge Code |
43752173
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.89 |
| Max. Negotiated Rate |
$79.04 |
| Rate for Payer: Aetna of IA Commercial |
$79.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$79.04
|
| Rate for Payer: Aetna of IA Medicare |
$50.06
|
| Rate for Payer: Amerigroup Medicaid |
$44.32
|
| Rate for Payer: Amerigroup Medicare |
$44.35
|
| Rate for Payer: Cash Price |
$70.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$43.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$43.89
|
| Rate for Payer: Medical Associates Commercial |
$65.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$43.91
|
| Rate for Payer: Midlands Choice Commercial |
$61.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$44.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$65.86
|
| Rate for Payer: United Healthcare Commercial |
$79.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$51.81
|
|
|
dipyridamole 5 mg/mL 10 ml IV SDV [VDMC]
|
Facility
IP
|
$87.82
|
|
|
Service Code
|
CPT J1245
|
| Hospital Charge Code |
43752173
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.47 |
| Max. Negotiated Rate |
$79.04 |
| Rate for Payer: Aetna of IA Commercial |
$79.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$79.04
|
| Rate for Payer: Cash Price |
$70.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$65.86
|
| Rate for Payer: Medical Associates Commercial |
$65.86
|
| Rate for Payer: Midlands Choice Commercial |
$61.47
|
| Rate for Payer: United Healthcare Commercial |
$79.04
|
|
