|
Probiotic Blend 2 billion Cap
|
Facility
OP
|
$1.23
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700527
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of IA Commercial |
$1.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.11
|
| 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 |
$0.99
|
| 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 |
$0.62
|
| 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 |
$0.62
|
| Rate for Payer: Midlands Choice Commercial |
$0.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.73
|
|
|
Procalcitonin DMCL
|
Facility
OP
|
$135.00
|
|
|
Service Code
|
CPT 84145
|
| Hospital Charge Code |
8132786
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$121.50 |
| Rate for Payer: Aetna of IA Commercial |
$121.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.50
|
| Rate for Payer: Aetna of IA Medicare |
$76.95
|
| Rate for Payer: Amerigroup Medicaid |
$68.13
|
| Rate for Payer: Amerigroup Medicare |
$68.18
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$101.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.47
|
| Rate for Payer: Medical Associates Commercial |
$101.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.50
|
| Rate for Payer: Midlands Choice Commercial |
$94.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$101.25
|
| Rate for Payer: United Healthcare Commercial |
$121.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$79.65
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
Procalcitonin DMCL
|
Facility
IP
|
$135.00
|
|
|
Service Code
|
CPT 84145
|
| Hospital Charge Code |
8132786
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$121.50 |
| Rate for Payer: Aetna of IA Commercial |
$121.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.50
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$101.25
|
| Rate for Payer: Medical Associates Commercial |
$101.25
|
| Rate for Payer: Midlands Choice Commercial |
$94.50
|
| Rate for Payer: United Healthcare Commercial |
$121.50
|
|
|
PROCEDURE PACK "3000-01-000"
|
Facility
OP
|
$2,160.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8930774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,079.57 |
| Max. Negotiated Rate |
$1,944.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,944.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,944.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,231.20
|
| Rate for Payer: Amerigroup Medicaid |
$1,090.15
|
| Rate for Payer: Amerigroup Medicare |
$1,090.80
|
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,620.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,080.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,079.57
|
| Rate for Payer: Medical Associates Commercial |
$1,620.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,080.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,512.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,096.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare Commercial |
$1,944.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,274.40
|
|
|
PROCEDURE PACK "3000-01-000"
|
Facility
IP
|
$2,160.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8930774
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,512.00 |
| Max. Negotiated Rate |
$1,944.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,944.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,944.00
|
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,620.00
|
| Rate for Payer: Medical Associates Commercial |
$1,620.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,512.00
|
| Rate for Payer: United Healthcare Commercial |
$1,944.00
|
|
|
prochlorperazine 25 mg Supp
|
Facility
IP
|
$28.03
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.62 |
| Max. Negotiated Rate |
$25.23 |
| Rate for Payer: Aetna of IA Commercial |
$25.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.23
|
| Rate for Payer: Cash Price |
$22.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.02
|
| Rate for Payer: Medical Associates Commercial |
$21.02
|
| Rate for Payer: Midlands Choice Commercial |
$19.62
|
| Rate for Payer: United Healthcare Commercial |
$25.23
|
|
|
prochlorperazine 25 mg Supp
|
Facility
OP
|
$28.03
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.01 |
| Max. Negotiated Rate |
$25.23 |
| Rate for Payer: Aetna of IA Commercial |
$25.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.23
|
| Rate for Payer: Aetna of IA Medicare |
$15.98
|
| Rate for Payer: Amerigroup Medicaid |
$14.15
|
| Rate for Payer: Amerigroup Medicare |
$14.16
|
| Rate for Payer: Cash Price |
$22.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.01
|
| Rate for Payer: Medical Associates Commercial |
$21.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.02
|
| Rate for Payer: Midlands Choice Commercial |
$19.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.23
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.02
|
| Rate for Payer: United Healthcare Commercial |
$25.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.54
|
|
|
prochlorperazine 5 mg/mL 2ml SDV Inj
|
Facility
IP
|
$38.54
|
|
|
Service Code
|
CPT J0780
|
| Hospital Charge Code |
43702286
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.98 |
| Max. Negotiated Rate |
$34.69 |
| Rate for Payer: Aetna of IA Commercial |
$34.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.69
|
| Rate for Payer: Cash Price |
$30.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.90
|
| Rate for Payer: Medical Associates Commercial |
$28.90
|
| Rate for Payer: Midlands Choice Commercial |
$26.98
|
| Rate for Payer: United Healthcare Commercial |
$34.69
|
|
|
prochlorperazine 5 mg/mL 2ml SDV Inj
|
Facility
OP
|
$38.54
|
|
|
Service Code
|
CPT J0780
|
| Hospital Charge Code |
43702286
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$34.69 |
| Rate for Payer: Aetna of IA Commercial |
$34.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.69
|
| Rate for Payer: Aetna of IA Medicare |
$21.97
|
| Rate for Payer: Amerigroup Medicaid |
$19.45
|
| Rate for Payer: Amerigroup Medicare |
$19.46
|
| Rate for Payer: Cash Price |
$30.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.26
|
| Rate for Payer: Medical Associates Commercial |
$28.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.27
|
| Rate for Payer: Midlands Choice Commercial |
$26.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$28.90
|
| Rate for Payer: United Healthcare Commercial |
$34.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.74
|
|
|
prochlorperazine 5 mg Tab
|
Facility
IP
|
$2.06
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Aetna of IA Commercial |
$1.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.85
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.54
|
| Rate for Payer: Medical Associates Commercial |
$1.54
|
| Rate for Payer: Midlands Choice Commercial |
$1.44
|
| Rate for Payer: United Healthcare Commercial |
$1.85
|
|
|
prochlorperazine 5 mg Tab
|
Facility
OP
|
$2.06
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Aetna of IA Commercial |
$1.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.85
|
| Rate for Payer: Aetna of IA Medicare |
$1.17
|
| Rate for Payer: Amerigroup Medicaid |
$1.04
|
| Rate for Payer: Amerigroup Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.03
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.03
|
| Rate for Payer: Medical Associates Commercial |
$1.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.03
|
| Rate for Payer: Midlands Choice Commercial |
$1.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$1.85
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.22
|
|
|
progesterone 50 mg/mL IM Sol 10 ml MDV
|
Facility
IP
|
$134.64
|
|
|
Service Code
|
CPT J2675
|
| Hospital Charge Code |
43700235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.25 |
| Max. Negotiated Rate |
$121.18 |
| Rate for Payer: Aetna of IA Commercial |
$121.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.18
|
| Rate for Payer: Cash Price |
$107.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$100.98
|
| Rate for Payer: Medical Associates Commercial |
$100.98
|
| Rate for Payer: Midlands Choice Commercial |
$94.25
|
| Rate for Payer: United Healthcare Commercial |
$121.18
|
|
|
progesterone 50 mg/mL IM Sol 10 ml MDV
|
Facility
OP
|
$134.64
|
|
|
Service Code
|
CPT J2675
|
| Hospital Charge Code |
43700235
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.29 |
| Max. Negotiated Rate |
$121.18 |
| Rate for Payer: Aetna of IA Commercial |
$121.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.18
|
| Rate for Payer: Aetna of IA Medicare |
$76.74
|
| Rate for Payer: Amerigroup Medicaid |
$67.95
|
| Rate for Payer: Amerigroup Medicare |
$67.99
|
| Rate for Payer: Cash Price |
$107.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$100.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.32
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.29
|
| Rate for Payer: Medical Associates Commercial |
$100.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.32
|
| Rate for Payer: Midlands Choice Commercial |
$94.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$100.98
|
| Rate for Payer: United Healthcare Commercial |
$121.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$79.44
|
|
|
Progesterone Level DMCL
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
8037782
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
|
|
Progesterone Level DMCL
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
8037782
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of IA Commercial |
$153.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$153.00
|
| Rate for Payer: Aetna of IA Medicare |
$96.90
|
| Rate for Payer: Amerigroup Medicaid |
$85.80
|
| Rate for Payer: Amerigroup Medicare |
$85.85
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$127.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$85.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$84.97
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$85.00
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$86.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$127.50
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.30
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
Prolactin DMCL
|
Facility
IP
|
$158.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
8037783
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
|
|
Prolactin DMCL
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
8037783
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Aetna of IA Medicare |
$90.06
|
| Rate for Payer: Amerigroup Medicaid |
$79.74
|
| Rate for Payer: Amerigroup Medicare |
$79.79
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$78.97
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.00
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$80.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$118.50
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$93.22
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
promethazine 25 mg/mL 1ml SDV
|
Facility
IP
|
$24.48
|
|
|
Service Code
|
CPT J2550
|
| Hospital Charge Code |
43702292
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.14 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna of IA Commercial |
$22.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.03
|
| Rate for Payer: Cash Price |
$19.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.36
|
| Rate for Payer: Medical Associates Commercial |
$18.36
|
| Rate for Payer: Midlands Choice Commercial |
$17.14
|
| Rate for Payer: United Healthcare Commercial |
$22.03
|
|
|
promethazine 25 mg/mL 1ml SDV
|
Facility
OP
|
$24.48
|
|
|
Service Code
|
CPT J2550
|
| Hospital Charge Code |
43702292
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna of IA Commercial |
$22.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.03
|
| Rate for Payer: Aetna of IA Medicare |
$13.95
|
| Rate for Payer: Amerigroup Medicaid |
$12.36
|
| Rate for Payer: Amerigroup Medicare |
$12.36
|
| Rate for Payer: Cash Price |
$19.58
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.24
|
| Rate for Payer: Medical Associates Commercial |
$18.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.24
|
| Rate for Payer: Midlands Choice Commercial |
$17.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.36
|
| Rate for Payer: United Healthcare Commercial |
$22.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.44
|
|
|
promethazine 25 mg Tab
|
Facility
IP
|
$1.63
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43787161
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Aetna of IA Commercial |
$1.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.47
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.22
|
| Rate for Payer: Medical Associates Commercial |
$1.22
|
| Rate for Payer: Midlands Choice Commercial |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.47
|
|
|
promethazine 25 mg Tab
|
Facility
OP
|
$1.63
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43787161
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: Aetna of IA Commercial |
$1.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.47
|
| Rate for Payer: Aetna of IA Medicare |
$0.93
|
| Rate for Payer: Amerigroup Medicaid |
$0.82
|
| Rate for Payer: Amerigroup Medicare |
$0.82
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.82
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.81
|
| Rate for Payer: Medical Associates Commercial |
$1.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.82
|
| Rate for Payer: Midlands Choice Commercial |
$1.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.22
|
| Rate for Payer: United Healthcare Commercial |
$1.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.96
|
|
|
promethazine 6.25 mg/5 mL Oral Syrup
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
43701331
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Aetna of IA Commercial |
$3.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.60
|
| Rate for Payer: Aetna of IA Medicare |
$2.28
|
| Rate for Payer: Amerigroup Medicaid |
$2.02
|
| Rate for Payer: Amerigroup Medicare |
$2.02
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.00
|
| Rate for Payer: Medical Associates Commercial |
$3.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.00
|
| Rate for Payer: Midlands Choice Commercial |
$2.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$3.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.36
|
|
|
promethazine 6.25 mg/5 mL Oral Syrup
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
43701331
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Aetna of IA Commercial |
$3.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.60
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.00
|
| Rate for Payer: Medical Associates Commercial |
$3.00
|
| Rate for Payer: Midlands Choice Commercial |
$2.80
|
| Rate for Payer: United Healthcare Commercial |
$3.60
|
|
|
promethazine-codein 6.25 mg-10mg/5 mL 5ml Oral Syrup
|
Facility
IP
|
$3.55
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706252
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of IA Commercial |
$3.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.20
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.66
|
| Rate for Payer: Medical Associates Commercial |
$2.66
|
| Rate for Payer: Midlands Choice Commercial |
$2.48
|
| Rate for Payer: United Healthcare Commercial |
$3.20
|
|
|
promethazine-codein 6.25 mg-10mg/5 mL 5ml Oral Syrup
|
Facility
OP
|
$3.55
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706252
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$3.20 |
| Rate for Payer: Aetna of IA Commercial |
$3.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.20
|
| Rate for Payer: Aetna of IA Medicare |
$2.02
|
| Rate for Payer: Amerigroup Medicaid |
$1.79
|
| Rate for Payer: Amerigroup Medicare |
$1.79
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.77
|
| Rate for Payer: Medical Associates Commercial |
$2.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.78
|
| Rate for Payer: Midlands Choice Commercial |
$2.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.66
|
| Rate for Payer: United Healthcare Commercial |
$3.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.09
|
|
