|
.DNA Double Stranded (dsDNA) Titer by IFA, IgG DMCL
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
8756831
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
DOBUTamine 250mg/20ml SDV vial
|
Facility
IP
|
$40.40
|
|
|
Service Code
|
CPT J1250
|
| Hospital Charge Code |
43700225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.28 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna of IA Commercial |
$36.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.36
|
| Rate for Payer: Cash Price |
$32.32
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.30
|
| Rate for Payer: Medical Associates Commercial |
$30.30
|
| Rate for Payer: Midlands Choice Commercial |
$28.28
|
| Rate for Payer: United Healthcare Commercial |
$36.36
|
|
|
DOBUTamine 250mg/20ml SDV vial
|
Facility
OP
|
$40.40
|
|
|
Service Code
|
CPT J1250
|
| Hospital Charge Code |
43700225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.19 |
| Max. Negotiated Rate |
$36.36 |
| Rate for Payer: Aetna of IA Commercial |
$36.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.36
|
| Rate for Payer: Aetna of IA Medicare |
$23.03
|
| Rate for Payer: Amerigroup Medicaid |
$20.39
|
| Rate for Payer: Amerigroup Medicare |
$20.40
|
| Rate for Payer: Cash Price |
$32.32
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.19
|
| Rate for Payer: Medical Associates Commercial |
$30.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.20
|
| Rate for Payer: Midlands Choice Commercial |
$28.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.30
|
| Rate for Payer: United Healthcare Commercial |
$36.36
|
| Rate for Payer: United Healthcare Managed Medicare |
$23.84
|
|
|
DOBUTamine in D5W 250mg/250mL soln
|
Facility
OP
|
$79.36
|
|
|
Service Code
|
CPT J1250
|
| Hospital Charge Code |
43702310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.66 |
| Max. Negotiated Rate |
$71.42 |
| Rate for Payer: Aetna of IA Commercial |
$71.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$71.42
|
| Rate for Payer: Aetna of IA Medicare |
$45.24
|
| Rate for Payer: Amerigroup Medicaid |
$40.05
|
| Rate for Payer: Amerigroup Medicare |
$40.08
|
| Rate for Payer: Cash Price |
$63.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$59.52
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$39.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$39.66
|
| Rate for Payer: Medical Associates Commercial |
$59.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$39.68
|
| Rate for Payer: Midlands Choice Commercial |
$55.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$40.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$59.52
|
| Rate for Payer: United Healthcare Commercial |
$71.42
|
| Rate for Payer: United Healthcare Managed Medicare |
$46.82
|
|
|
DOBUTamine in D5W 250mg/250mL soln
|
Facility
IP
|
$79.36
|
|
|
Service Code
|
CPT J1250
|
| Hospital Charge Code |
43702310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.55 |
| Max. Negotiated Rate |
$71.42 |
| Rate for Payer: Aetna of IA Commercial |
$71.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$71.42
|
| Rate for Payer: Cash Price |
$63.49
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$59.52
|
| Rate for Payer: Medical Associates Commercial |
$59.52
|
| Rate for Payer: Midlands Choice Commercial |
$55.55
|
| Rate for Payer: United Healthcare Commercial |
$71.42
|
|
|
DOCEtaxel 10 mg/mL16 ml MDV
|
Facility
IP
|
$402.68
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43707652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$281.88 |
| Max. Negotiated Rate |
$362.41 |
| Rate for Payer: Aetna of IA Commercial |
$362.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$362.41
|
| Rate for Payer: Cash Price |
$322.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$302.01
|
| Rate for Payer: Medical Associates Commercial |
$302.01
|
| Rate for Payer: Midlands Choice Commercial |
$281.88
|
| Rate for Payer: United Healthcare Commercial |
$362.41
|
|
|
DOCEtaxel 10 mg/mL16 ml MDV
|
Facility
OP
|
$402.68
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43707652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$201.26 |
| Max. Negotiated Rate |
$362.41 |
| Rate for Payer: Aetna of IA Commercial |
$362.41
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$362.41
|
| Rate for Payer: Aetna of IA Medicare |
$229.53
|
| Rate for Payer: Amerigroup Medicaid |
$203.23
|
| Rate for Payer: Amerigroup Medicare |
$203.35
|
| Rate for Payer: Cash Price |
$322.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$302.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$201.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$201.26
|
| Rate for Payer: Medical Associates Commercial |
$302.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$201.34
|
| Rate for Payer: Midlands Choice Commercial |
$281.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$204.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$302.01
|
| Rate for Payer: United Healthcare Commercial |
$362.41
|
| Rate for Payer: United Healthcare Managed Medicare |
$237.58
|
|
|
DOCEtaxel 10 mg/mL 2 ml SDV
|
Facility
OP
|
$117.56
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43700372
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.76 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna of IA Commercial |
$105.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$105.80
|
| Rate for Payer: Aetna of IA Medicare |
$67.01
|
| Rate for Payer: Amerigroup Medicaid |
$59.33
|
| Rate for Payer: Amerigroup Medicare |
$59.37
|
| Rate for Payer: Cash Price |
$94.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$88.17
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$58.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$58.76
|
| Rate for Payer: Medical Associates Commercial |
$88.17
|
| Rate for Payer: Medical Associates Managed Medicare |
$58.78
|
| Rate for Payer: Midlands Choice Commercial |
$82.29
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$59.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$88.17
|
| Rate for Payer: United Healthcare Commercial |
$105.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$69.36
|
|
|
DOCEtaxel 10 mg/mL 2 ml SDV
|
Facility
IP
|
$117.56
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43700372
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.29 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna of IA Commercial |
$105.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$105.80
|
| Rate for Payer: Cash Price |
$94.05
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$88.17
|
| Rate for Payer: Medical Associates Commercial |
$88.17
|
| Rate for Payer: Midlands Choice Commercial |
$82.29
|
| Rate for Payer: United Healthcare Commercial |
$105.80
|
|
|
DOCEtaxel 20 mg/ml 1ml MDV
|
Facility
OP
|
$108.52
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43700136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.24 |
| Max. Negotiated Rate |
$97.67 |
| Rate for Payer: Aetna of IA Commercial |
$97.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.67
|
| Rate for Payer: Aetna of IA Medicare |
$61.86
|
| Rate for Payer: Amerigroup Medicaid |
$54.77
|
| Rate for Payer: Amerigroup Medicare |
$54.80
|
| Rate for Payer: Cash Price |
$86.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$54.26
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$54.24
|
| Rate for Payer: Medical Associates Commercial |
$81.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$54.26
|
| Rate for Payer: Midlands Choice Commercial |
$75.96
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$55.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.39
|
| Rate for Payer: United Healthcare Commercial |
$97.67
|
| Rate for Payer: United Healthcare Managed Medicare |
$64.03
|
|
|
DOCEtaxel 20 mg/ml 1ml MDV
|
Facility
IP
|
$108.52
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43700136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.96 |
| Max. Negotiated Rate |
$97.67 |
| Rate for Payer: Aetna of IA Commercial |
$97.67
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$97.67
|
| Rate for Payer: Cash Price |
$86.82
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$81.39
|
| Rate for Payer: Medical Associates Commercial |
$81.39
|
| Rate for Payer: Midlands Choice Commercial |
$75.96
|
| Rate for Payer: United Healthcare Commercial |
$97.67
|
|
|
DOCEtaxel 20 mg/mL 4 ml MDV
|
Facility
OP
|
$283.84
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43700128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.86 |
| Max. Negotiated Rate |
$255.46 |
| Rate for Payer: Aetna of IA Commercial |
$255.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$255.46
|
| Rate for Payer: Aetna of IA Medicare |
$161.79
|
| Rate for Payer: Amerigroup Medicaid |
$143.25
|
| Rate for Payer: Amerigroup Medicare |
$143.34
|
| Rate for Payer: Cash Price |
$227.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$212.88
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$141.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$141.86
|
| Rate for Payer: Medical Associates Commercial |
$212.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$141.92
|
| Rate for Payer: Midlands Choice Commercial |
$198.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$144.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$212.88
|
| Rate for Payer: United Healthcare Commercial |
$255.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$167.47
|
|
|
DOCEtaxel 20 mg/mL 4 ml MDV
|
Facility
IP
|
$283.84
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43700128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.69 |
| Max. Negotiated Rate |
$255.46 |
| Rate for Payer: Aetna of IA Commercial |
$255.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$255.46
|
| Rate for Payer: Cash Price |
$227.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$212.88
|
| Rate for Payer: Medical Associates Commercial |
$212.88
|
| Rate for Payer: Midlands Choice Commercial |
$198.69
|
| Rate for Payer: United Healthcare Commercial |
$255.46
|
|
|
DOCEtaxel 20 mg/mL 8 ml Sol MDV
|
Facility
IP
|
$487.44
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43700523
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$341.21 |
| Max. Negotiated Rate |
$438.70 |
| Rate for Payer: Aetna of IA Commercial |
$438.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$438.70
|
| Rate for Payer: Cash Price |
$389.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$365.58
|
| Rate for Payer: Medical Associates Commercial |
$365.58
|
| Rate for Payer: Midlands Choice Commercial |
$341.21
|
| Rate for Payer: United Healthcare Commercial |
$438.70
|
|
|
DOCEtaxel 20 mg/mL 8 ml Sol MDV
|
Facility
OP
|
$487.44
|
|
|
Service Code
|
CPT J9171
|
| Hospital Charge Code |
43700523
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.62 |
| Max. Negotiated Rate |
$438.70 |
| Rate for Payer: Aetna of IA Commercial |
$438.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$438.70
|
| Rate for Payer: Aetna of IA Medicare |
$277.84
|
| Rate for Payer: Amerigroup Medicaid |
$246.01
|
| Rate for Payer: Amerigroup Medicare |
$246.16
|
| Rate for Payer: Cash Price |
$389.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$365.58
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$243.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$243.62
|
| Rate for Payer: Medical Associates Commercial |
$365.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$243.72
|
| Rate for Payer: Midlands Choice Commercial |
$341.21
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$247.38
|
| Rate for Payer: Partners Health Alliance Commercial |
$365.58
|
| Rate for Payer: United Healthcare Commercial |
$438.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$287.59
|
|
|
docusate sodium 100 mg Cap
|
Facility
OP
|
$1.22
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701942
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Aetna of IA Medicare |
$0.70
|
| Rate for Payer: Amerigroup Medicaid |
$0.62
|
| Rate for Payer: Amerigroup Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.61
|
| Rate for Payer: Medical Associates Commercial |
$0.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.61
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.72
|
|
|
docusate sodium 100 mg Cap
|
Facility
IP
|
$1.22
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701942
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of IA Commercial |
$1.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.10
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.92
|
| Rate for Payer: Medical Associates Commercial |
$0.92
|
| Rate for Payer: Midlands Choice Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
|
|
docusate sodium 150 mg/15 mL Oral Liq
|
Facility
OP
|
$2.88
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Aetna of IA Commercial |
$2.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.59
|
| Rate for Payer: Aetna of IA Medicare |
$1.64
|
| Rate for Payer: Amerigroup Medicaid |
$1.45
|
| Rate for Payer: Amerigroup Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.44
|
| Rate for Payer: Medical Associates Commercial |
$2.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.44
|
| Rate for Payer: Midlands Choice Commercial |
$2.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.16
|
| Rate for Payer: United Healthcare Commercial |
$2.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.70
|
|
|
docusate sodium 150 mg/15 mL Oral Liq
|
Facility
IP
|
$2.88
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Aetna of IA Commercial |
$2.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.16
|
| Rate for Payer: Medical Associates Commercial |
$2.16
|
| Rate for Payer: Midlands Choice Commercial |
$2.02
|
| Rate for Payer: United Healthcare Commercial |
$2.59
|
|
|
donepezil 10 mg Tab
|
Facility
IP
|
$1.45
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.09
|
| Rate for Payer: Medical Associates Commercial |
$1.09
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
|
|
donepezil 10 mg Tab
|
Facility
OP
|
$1.45
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705969
|
|
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 |
$0.83
|
| Rate for Payer: Amerigroup Medicaid |
$0.73
|
| Rate for Payer: Amerigroup Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.72
|
| Rate for Payer: Medical Associates Commercial |
$1.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.73
|
| Rate for Payer: Midlands Choice Commercial |
$1.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.86
|
|
|
dopamine/dextrose 5% 400MG/250ML
|
Facility
IP
|
$102.26
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
43702048
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.58 |
| Max. Negotiated Rate |
$92.03 |
| Rate for Payer: Aetna of IA Commercial |
$92.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$92.03
|
| Rate for Payer: Cash Price |
$81.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$76.70
|
| Rate for Payer: Medical Associates Commercial |
$76.70
|
| Rate for Payer: Midlands Choice Commercial |
$71.58
|
| Rate for Payer: United Healthcare Commercial |
$92.03
|
|
|
dopamine/dextrose 5% 400MG/250ML
|
Facility
OP
|
$102.26
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
43702048
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.11 |
| Max. Negotiated Rate |
$92.03 |
| Rate for Payer: Aetna of IA Commercial |
$92.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$92.03
|
| Rate for Payer: Aetna of IA Medicare |
$58.29
|
| Rate for Payer: Amerigroup Medicaid |
$51.61
|
| Rate for Payer: Amerigroup Medicare |
$51.64
|
| Rate for Payer: Cash Price |
$81.81
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$76.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.13
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$51.11
|
| Rate for Payer: Medical Associates Commercial |
$76.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.13
|
| Rate for Payer: Midlands Choice Commercial |
$71.58
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$51.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$76.70
|
| Rate for Payer: United Healthcare Commercial |
$92.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$60.33
|
|
|
dorzolamide Ophth 2% Sol 10 ml
|
Facility
IP
|
$52.24
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705800
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.57 |
| Max. Negotiated Rate |
$47.02 |
| Rate for Payer: Aetna of IA Commercial |
$47.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.02
|
| Rate for Payer: Cash Price |
$41.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.18
|
| Rate for Payer: Medical Associates Commercial |
$39.18
|
| Rate for Payer: Midlands Choice Commercial |
$36.57
|
| Rate for Payer: United Healthcare Commercial |
$47.02
|
|
|
dorzolamide Ophth 2% Sol 10 ml
|
Facility
OP
|
$52.24
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705800
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.11 |
| Max. Negotiated Rate |
$47.02 |
| Rate for Payer: Aetna of IA Commercial |
$47.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.02
|
| Rate for Payer: Aetna of IA Medicare |
$29.78
|
| Rate for Payer: Amerigroup Medicaid |
$26.37
|
| Rate for Payer: Amerigroup Medicare |
$26.38
|
| Rate for Payer: Cash Price |
$41.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.18
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.11
|
| Rate for Payer: Medical Associates Commercial |
$39.18
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.12
|
| Rate for Payer: Midlands Choice Commercial |
$36.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.18
|
| Rate for Payer: United Healthcare Commercial |
$47.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.82
|
|
