|
HYDROmorphone 2 mg/mL syringe 1mL
|
Facility
OP
|
$48.65
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
43725250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.32 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Aetna of IA Commercial |
$43.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.78
|
| Rate for Payer: Aetna of IA Medicare |
$27.73
|
| Rate for Payer: Amerigroup Medicaid |
$24.55
|
| Rate for Payer: Amerigroup Medicare |
$24.57
|
| Rate for Payer: Cash Price |
$38.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.49
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.32
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.32
|
| Rate for Payer: Medical Associates Commercial |
$36.49
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.32
|
| Rate for Payer: Midlands Choice Commercial |
$34.06
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.49
|
| Rate for Payer: United Healthcare Commercial |
$43.78
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.70
|
|
|
HYDROmorphone 2 mg/mL syringe 1mL
|
Facility
IP
|
$48.65
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
43725250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.06 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Aetna of IA Commercial |
$43.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.78
|
| Rate for Payer: Cash Price |
$38.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.49
|
| Rate for Payer: Medical Associates Commercial |
$36.49
|
| Rate for Payer: Midlands Choice Commercial |
$34.06
|
| Rate for Payer: United Healthcare Commercial |
$43.78
|
|
|
HYDROmorphone 2 mg/mL vial
|
Facility
IP
|
$45.31
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
43700204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.72 |
| Max. Negotiated Rate |
$40.78 |
| Rate for Payer: Aetna of IA Commercial |
$40.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$40.78
|
| Rate for Payer: Cash Price |
$36.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.98
|
| Rate for Payer: Medical Associates Commercial |
$33.98
|
| Rate for Payer: Midlands Choice Commercial |
$31.72
|
| Rate for Payer: United Healthcare Commercial |
$40.78
|
|
|
HYDROmorphone 2 mg/mL vial
|
Facility
OP
|
$45.31
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
43700204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.65 |
| Max. Negotiated Rate |
$40.78 |
| Rate for Payer: Aetna of IA Commercial |
$40.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$40.78
|
| Rate for Payer: Aetna of IA Medicare |
$25.83
|
| Rate for Payer: Amerigroup Medicaid |
$22.87
|
| Rate for Payer: Amerigroup Medicare |
$22.88
|
| Rate for Payer: Cash Price |
$36.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.65
|
| Rate for Payer: Medical Associates Commercial |
$33.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.66
|
| Rate for Payer: Midlands Choice Commercial |
$31.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.98
|
| Rate for Payer: United Healthcare Commercial |
$40.78
|
| Rate for Payer: United Healthcare Managed Medicare |
$26.73
|
|
|
HYDROmorphone 2 mg Tab
|
Facility
OP
|
$3.65
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702730
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna of IA Commercial |
$3.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.28
|
| Rate for Payer: Aetna of IA Medicare |
$2.08
|
| Rate for Payer: Amerigroup Medicaid |
$1.84
|
| Rate for Payer: Amerigroup Medicare |
$1.84
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.74
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.82
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.82
|
| Rate for Payer: Medical Associates Commercial |
$2.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.82
|
| Rate for Payer: Midlands Choice Commercial |
$2.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.74
|
| Rate for Payer: United Healthcare Commercial |
$3.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.15
|
|
|
HYDROmorphone 2 mg Tab
|
Facility
IP
|
$3.65
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702730
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna of IA Commercial |
$3.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.28
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.74
|
| Rate for Payer: Medical Associates Commercial |
$2.74
|
| Rate for Payer: Midlands Choice Commercial |
$2.56
|
| Rate for Payer: United Healthcare Commercial |
$3.28
|
|
|
HYDROmorphone 4 mg/mL Inj Sol
|
Facility
OP
|
$47.19
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
43700399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.59 |
| Max. Negotiated Rate |
$42.47 |
| Rate for Payer: Aetna of IA Commercial |
$42.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$42.47
|
| Rate for Payer: Aetna of IA Medicare |
$26.90
|
| Rate for Payer: Amerigroup Medicaid |
$23.82
|
| Rate for Payer: Amerigroup Medicare |
$23.83
|
| Rate for Payer: Cash Price |
$37.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$35.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$23.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.59
|
| Rate for Payer: Medical Associates Commercial |
$35.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.60
|
| Rate for Payer: Midlands Choice Commercial |
$33.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$23.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$35.39
|
| Rate for Payer: United Healthcare Commercial |
$42.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$27.84
|
|
|
HYDROmorphone 4 mg/mL Inj Sol
|
Facility
IP
|
$47.19
|
|
|
Service Code
|
CPT J1170
|
| Hospital Charge Code |
43700399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.03 |
| Max. Negotiated Rate |
$42.47 |
| Rate for Payer: Aetna of IA Commercial |
$42.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$42.47
|
| Rate for Payer: Cash Price |
$37.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$35.39
|
| Rate for Payer: Medical Associates Commercial |
$35.39
|
| Rate for Payer: Midlands Choice Commercial |
$33.03
|
| Rate for Payer: United Healthcare Commercial |
$42.47
|
|
|
hydrophilic ointment 454 gm
|
Facility
OP
|
$52.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Aetna of IA Medicare |
$29.64
|
| Rate for Payer: Amerigroup Medicaid |
$26.24
|
| Rate for Payer: Amerigroup Medicare |
$26.26
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$25.99
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.00
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.00
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$30.68
|
|
|
hydrophilic ointment 454 gm
|
Facility
IP
|
$52.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna of IA Commercial |
$46.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$46.80
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.00
|
| Rate for Payer: Medical Associates Commercial |
$39.00
|
| Rate for Payer: Midlands Choice Commercial |
$36.40
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
|
|
HYDROPHILIC WOUND DRESSING 85 GRAM
|
Facility
OP
|
$64.00
|
|
| Hospital Charge Code |
8013714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.99 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna of IA Commercial |
$57.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.60
|
| Rate for Payer: Aetna of IA Medicare |
$36.48
|
| Rate for Payer: Amerigroup Medicaid |
$32.30
|
| Rate for Payer: Amerigroup Medicare |
$32.32
|
| Rate for Payer: Cash Price |
$51.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.99
|
| Rate for Payer: Medical Associates Commercial |
$48.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.00
|
| Rate for Payer: Midlands Choice Commercial |
$44.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$32.48
|
| Rate for Payer: Partners Health Alliance Commercial |
$48.00
|
| Rate for Payer: United Healthcare Commercial |
$57.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.76
|
|
|
HYDROPHILIC WOUND DRESSING 85 GRAM
|
Facility
IP
|
$64.00
|
|
| Hospital Charge Code |
8013714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna of IA Commercial |
$57.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$57.60
|
| Rate for Payer: Cash Price |
$51.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.00
|
| Rate for Payer: Medical Associates Commercial |
$48.00
|
| Rate for Payer: Midlands Choice Commercial |
$44.80
|
| Rate for Payer: United Healthcare Commercial |
$57.60
|
|
|
Hydrophilic Wound Dressing oint tube
|
Facility
IP
|
$8.38
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700548
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$7.54 |
| Rate for Payer: Aetna of IA Commercial |
$7.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.54
|
| Rate for Payer: Cash Price |
$6.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.28
|
| Rate for Payer: Medical Associates Commercial |
$6.28
|
| Rate for Payer: Midlands Choice Commercial |
$5.87
|
| Rate for Payer: United Healthcare Commercial |
$7.54
|
|
|
Hydrophilic Wound Dressing oint tube
|
Facility
OP
|
$8.38
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700548
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$7.54 |
| Rate for Payer: Aetna of IA Commercial |
$7.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.54
|
| Rate for Payer: Aetna of IA Medicare |
$4.78
|
| Rate for Payer: Amerigroup Medicaid |
$4.23
|
| Rate for Payer: Amerigroup Medicare |
$4.23
|
| Rate for Payer: Cash Price |
$6.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.19
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.19
|
| Rate for Payer: Medical Associates Commercial |
$6.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.19
|
| Rate for Payer: Midlands Choice Commercial |
$5.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.28
|
| Rate for Payer: United Healthcare Commercial |
$7.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.94
|
|
|
hydroxychloroquine 200 mg Tab
|
Facility
IP
|
$1.68
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702733
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna of IA Commercial |
$1.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.51
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.26
|
| Rate for Payer: Medical Associates Commercial |
$1.26
|
| Rate for Payer: Midlands Choice Commercial |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.51
|
|
|
hydroxychloroquine 200 mg Tab
|
Facility
OP
|
$1.68
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702733
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna of IA Commercial |
$1.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.51
|
| Rate for Payer: Aetna of IA Medicare |
$0.96
|
| Rate for Payer: Amerigroup Medicaid |
$0.85
|
| Rate for Payer: Amerigroup Medicare |
$0.85
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.26
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.84
|
| Rate for Payer: Medical Associates Commercial |
$1.26
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.84
|
| Rate for Payer: Midlands Choice Commercial |
$1.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.26
|
| Rate for Payer: United Healthcare Commercial |
$1.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.99
|
|
|
hydroxyurEA 500 mg Cap
|
Facility
OP
|
$2.30
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43758945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Aetna of IA Commercial |
$2.07
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.07
|
| Rate for Payer: Aetna of IA Medicare |
$1.31
|
| Rate for Payer: Amerigroup Medicaid |
$1.16
|
| Rate for Payer: Amerigroup Medicare |
$1.16
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.15
|
| Rate for Payer: Medical Associates Commercial |
$1.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.15
|
| Rate for Payer: Midlands Choice Commercial |
$1.61
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.72
|
| Rate for Payer: United Healthcare Commercial |
$2.07
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.36
|
|
|
hydroxyurEA 500 mg Cap
|
Facility
IP
|
$2.30
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43758945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Aetna of IA Commercial |
$2.07
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.07
|
| Rate for Payer: Cash Price |
$1.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.72
|
| Rate for Payer: Medical Associates Commercial |
$1.72
|
| Rate for Payer: Midlands Choice Commercial |
$1.61
|
| Rate for Payer: United Healthcare Commercial |
$2.07
|
|
|
hydrOXYzine hydrochloride 10 mg/5 mL 118ml Syr
|
Facility
OP
|
$36.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702152
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$32.94 |
| Rate for Payer: Aetna of IA Commercial |
$32.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.94
|
| Rate for Payer: Aetna of IA Medicare |
$20.86
|
| Rate for Payer: Amerigroup Medicaid |
$18.47
|
| Rate for Payer: Amerigroup Medicare |
$18.48
|
| Rate for Payer: Cash Price |
$29.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$27.45
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.29
|
| Rate for Payer: Medical Associates Commercial |
$27.45
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.30
|
| Rate for Payer: Midlands Choice Commercial |
$25.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$27.45
|
| Rate for Payer: United Healthcare Commercial |
$32.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$21.59
|
|
|
hydrOXYzine hydrochloride 10 mg/5 mL 118ml Syr
|
Facility
IP
|
$36.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702152
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$32.94 |
| Rate for Payer: Aetna of IA Commercial |
$32.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.94
|
| Rate for Payer: Cash Price |
$29.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$27.45
|
| Rate for Payer: Medical Associates Commercial |
$27.45
|
| Rate for Payer: Midlands Choice Commercial |
$25.62
|
| Rate for Payer: United Healthcare Commercial |
$32.94
|
|
|
hydrOXYzine hydrochloride 10 mg Tab
|
Facility
IP
|
$1.11
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of IA Commercial |
$1.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.00
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.83
|
| Rate for Payer: Medical Associates Commercial |
$0.83
|
| Rate for Payer: Midlands Choice Commercial |
$0.78
|
| Rate for Payer: United Healthcare Commercial |
$1.00
|
|
|
hydrOXYzine hydrochloride 10 mg Tab
|
Facility
OP
|
$1.11
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of IA Commercial |
$1.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.00
|
| Rate for Payer: Aetna of IA Medicare |
$0.63
|
| Rate for Payer: Amerigroup Medicaid |
$0.56
|
| Rate for Payer: Amerigroup Medicare |
$0.56
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.83
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.55
|
| Rate for Payer: Medical Associates Commercial |
$0.83
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.56
|
| Rate for Payer: Midlands Choice Commercial |
$0.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.83
|
| Rate for Payer: United Healthcare Commercial |
$1.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.65
|
|
|
hydrOXYzine hydrochloride 25 mg/mL Sol
|
Facility
OP
|
$72.40
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
43705884
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.19 |
| Max. Negotiated Rate |
$65.16 |
| Rate for Payer: Aetna of IA Commercial |
$65.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$65.16
|
| Rate for Payer: Aetna of IA Medicare |
$41.27
|
| Rate for Payer: Amerigroup Medicaid |
$36.54
|
| Rate for Payer: Amerigroup Medicare |
$36.56
|
| Rate for Payer: Cash Price |
$57.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.30
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$36.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$36.19
|
| Rate for Payer: Medical Associates Commercial |
$54.30
|
| Rate for Payer: Medical Associates Managed Medicare |
$36.20
|
| Rate for Payer: Midlands Choice Commercial |
$50.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$36.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$54.30
|
| Rate for Payer: United Healthcare Commercial |
$65.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$42.72
|
|
|
hydrOXYzine hydrochloride 25 mg/mL Sol
|
Facility
IP
|
$72.40
|
|
|
Service Code
|
CPT J3410
|
| Hospital Charge Code |
43705884
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$65.16 |
| Rate for Payer: Aetna of IA Commercial |
$65.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$65.16
|
| Rate for Payer: Cash Price |
$57.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.30
|
| Rate for Payer: Medical Associates Commercial |
$54.30
|
| Rate for Payer: Midlands Choice Commercial |
$50.68
|
| Rate for Payer: United Healthcare Commercial |
$65.16
|
|
|
hydrOXYzine hydrochloride 25 mg Tab
|
Facility
OP
|
$1.56
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701891
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Aetna of IA Commercial |
$1.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.40
|
| Rate for Payer: Aetna of IA Medicare |
$0.89
|
| Rate for Payer: Amerigroup Medicaid |
$0.79
|
| Rate for Payer: Amerigroup Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.17
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.78
|
| Rate for Payer: Medical Associates Commercial |
$1.17
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.78
|
| Rate for Payer: Midlands Choice Commercial |
$1.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.17
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.92
|
|
