|
primidone 250 mg Tab [VDMC]
|
Facility
|
OP
|
$2.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of IA Commercial |
$1.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.94
|
| Rate for Payer: Aetna of IA Medicare |
$1.23
|
| Rate for Payer: Amerigroup Medicaid |
$1.24
|
| Rate for Payer: Amerigroup Medicare |
$0.98
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.61
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.23
|
| Rate for Payer: Medical Associates Commercial |
$1.61
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.97
|
| Rate for Payer: Midlands Choice Commercial |
$1.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.27
|
|
|
primidone 250 mg Tab [VDMC]
|
Facility
|
IP
|
$2.15
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of IA Commercial |
$1.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.94
|
| Rate for Payer: Cash Price |
$1.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.61
|
| Rate for Payer: Medical Associates Commercial |
$1.61
|
| Rate for Payer: Midlands Choice Commercial |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$1.94
|
|
|
primidone 50 mg Tab [VDMC]
|
Facility
|
OP
|
$3.14
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna of IA Commercial |
$2.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.83
|
| Rate for Payer: Aetna of IA Medicare |
$1.79
|
| Rate for Payer: Amerigroup Medicaid |
$1.81
|
| Rate for Payer: Amerigroup Medicare |
$1.43
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.41
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.79
|
| Rate for Payer: Medical Associates Commercial |
$2.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.41
|
| Rate for Payer: Midlands Choice Commercial |
$2.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.62
|
| Rate for Payer: United Healthcare Commercial |
$2.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.85
|
|
|
primidone 50 mg Tab [VDMC]
|
Facility
|
IP
|
$3.14
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416122
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Aetna of IA Commercial |
$2.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.83
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.35
|
| Rate for Payer: Medical Associates Commercial |
$2.35
|
| Rate for Payer: Midlands Choice Commercial |
$2.20
|
| Rate for Payer: United Healthcare Commercial |
$2.83
|
|
|
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
|
|
|
Procalcitonin DMCL
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
CPT 84145
|
| Hospital Charge Code |
8132786
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.63 |
| 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 |
$77.87
|
| Rate for Payer: Amerigroup Medicare |
$61.36
|
| 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 |
$60.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$77.11
|
| Rate for Payer: Medical Associates Commercial |
$101.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$60.75
|
| Rate for Payer: Midlands Choice Commercial |
$94.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$78.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$69.86
|
| Rate for Payer: United Healthcare Commercial |
$121.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$79.65
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
prochlorperazine 25 mg Supp [VDMC]
|
Facility
|
IP
|
$28.03
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416260
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$28.03
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416260
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.61 |
| 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 |
$16.17
|
| Rate for Payer: Amerigroup Medicare |
$12.74
|
| 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 |
$12.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.01
|
| Rate for Payer: Medical Associates Commercial |
$21.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.61
|
| Rate for Payer: Midlands Choice Commercial |
$19.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$14.51
|
| Rate for Payer: United Healthcare Commercial |
$25.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.54
|
|
|
prochlorperazine 5 mg/mL 2ml SDV Inj [VDMC]
|
Facility
|
IP
|
$29.64
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
10416394
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna of IA Commercial |
$26.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.68
|
| Rate for Payer: Cash Price |
$23.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.23
|
| Rate for Payer: Medical Associates Commercial |
$22.23
|
| Rate for Payer: Midlands Choice Commercial |
$20.75
|
| Rate for Payer: United Healthcare Commercial |
$26.68
|
|
|
prochlorperazine 5 mg/mL 2ml SDV Inj [VDMC]
|
Facility
|
OP
|
$29.64
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
10416394
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$26.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.68
|
| Rate for Payer: Aetna of IA Medicare |
$16.90
|
| Rate for Payer: Amerigroup Medicaid |
$17.10
|
| Rate for Payer: Amerigroup Medicare |
$13.47
|
| Rate for Payer: Cash Price |
$23.71
|
| Rate for Payer: Cash Price |
$23.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.23
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.93
|
| Rate for Payer: Medical Associates Commercial |
$22.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.34
|
| Rate for Payer: Midlands Choice Commercial |
$20.75
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.34
|
| Rate for Payer: United Healthcare Commercial |
$26.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.49
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
prochlorperazine 5 mg Tab [VDMC]
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416325
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| 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 |
$1.19
|
| Rate for Payer: Amerigroup Medicare |
$0.93
|
| 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 |
$0.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.17
|
| Rate for Payer: Medical Associates Commercial |
$1.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.93
|
| Rate for Payer: Midlands Choice Commercial |
$1.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.06
|
| Rate for Payer: United Healthcare Commercial |
$1.85
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.21
|
|
|
prochlorperazine 5 mg Tab [VDMC]
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416325
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
progesterone 50 mg/mL IM Sol 10 ml MDV [VDMC]
|
Facility
|
IP
|
$134.64
|
|
|
Service Code
|
HCPCS J2675
|
| Hospital Charge Code |
10416465
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$134.64
|
|
|
Service Code
|
HCPCS J2675
|
| Hospital Charge Code |
10416465
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$60.59 |
| Max. Negotiated Rate |
$221.80 |
| 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 |
$77.66
|
| Rate for Payer: Amerigroup Medicare |
$61.19
|
| Rate for Payer: Cash Price |
$107.71
|
| 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 |
$60.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$76.91
|
| Rate for Payer: Medical Associates Commercial |
$100.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$60.59
|
| Rate for Payer: Midlands Choice Commercial |
$94.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$78.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$69.68
|
| Rate for Payer: United Healthcare Commercial |
$121.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$79.44
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
Progesterone Level DMCL
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
8037782
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.63 |
| 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 |
$98.06
|
| Rate for Payer: Amerigroup Medicare |
$77.26
|
| 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 |
$76.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$97.10
|
| Rate for Payer: Medical Associates Commercial |
$127.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$76.50
|
| Rate for Payer: Midlands Choice Commercial |
$119.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$98.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$87.98
|
| Rate for Payer: United Healthcare Commercial |
$153.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$100.30
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
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
|
|
|
PRO GRIP 10X15CM LP FLATSHEET MESH
|
Facility
|
OP
|
$513.14
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8969718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.91 |
| Max. Negotiated Rate |
$461.83 |
| Rate for Payer: Aetna of IA Commercial |
$461.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$461.83
|
| Rate for Payer: Aetna of IA Medicare |
$292.49
|
| Rate for Payer: Amerigroup Medicaid |
$295.98
|
| Rate for Payer: Amerigroup Medicare |
$233.22
|
| Rate for Payer: Cash Price |
$410.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$384.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$230.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$293.11
|
| Rate for Payer: Medical Associates Commercial |
$384.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$230.91
|
| Rate for Payer: Midlands Choice Commercial |
$359.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$297.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$265.55
|
| Rate for Payer: United Healthcare Commercial |
$461.83
|
| Rate for Payer: United Healthcare Managed Medicare |
$302.75
|
|
|
PRO GRIP 10X15CM LP FLATSHEET MESH
|
Facility
|
IP
|
$513.14
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
8969718
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$359.20 |
| Max. Negotiated Rate |
$461.83 |
| Rate for Payer: Aetna of IA Commercial |
$461.83
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$461.83
|
| Rate for Payer: Cash Price |
$410.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$384.86
|
| Rate for Payer: Medical Associates Commercial |
$384.86
|
| Rate for Payer: Midlands Choice Commercial |
$359.20
|
| Rate for Payer: United Healthcare Commercial |
$461.83
|
|
|
Prolactin DMCL
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
8037783
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.63 |
| 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 |
$91.13
|
| Rate for Payer: Amerigroup Medicare |
$71.81
|
| 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 |
$71.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$90.25
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$71.10
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$81.76
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$93.22
|
| Rate for Payer: Wellmark IA HMO WHPI |
$49.63
|
| Rate for Payer: Wellmark IA PPO |
$54.67
|
|
|
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
|
|
|
promethazine 25 mg/mL 1ml SDV [VDMC]
|
Facility
|
IP
|
$24.48
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
11554245
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.13 |
| 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 |
$17.13
|
| Rate for Payer: United Healthcare Commercial |
$22.03
|
|
|
promethazine 25 mg/mL 1ml SDV [VDMC]
|
Facility
|
OP
|
$24.48
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
11554245
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.01 |
| Max. Negotiated Rate |
$221.80 |
| 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 |
$14.12
|
| Rate for Payer: Amerigroup Medicare |
$11.12
|
| Rate for Payer: Cash Price |
$19.58
|
| 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 |
$11.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.98
|
| Rate for Payer: Medical Associates Commercial |
$18.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.01
|
| Rate for Payer: Midlands Choice Commercial |
$17.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.67
|
| Rate for Payer: United Healthcare Commercial |
$22.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.44
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
promethazine 25 mg Supp [VDMC]
|
Facility
|
OP
|
$21.51
|
|
|
Service Code
|
NDC 00713-0526-12
|
| Hospital Charge Code |
10416664
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$19.36 |
| Rate for Payer: Aetna of IA Commercial |
$19.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.36
|
| Rate for Payer: Aetna of IA Medicare |
$12.26
|
| Rate for Payer: Amerigroup Medicaid |
$12.41
|
| Rate for Payer: Amerigroup Medicare |
$9.78
|
| Rate for Payer: Cash Price |
$17.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.13
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.29
|
| Rate for Payer: Medical Associates Commercial |
$16.13
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.68
|
| Rate for Payer: Midlands Choice Commercial |
$15.06
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.13
|
| Rate for Payer: United Healthcare Commercial |
$19.36
|
| Rate for Payer: United Healthcare Managed Medicare |
$12.69
|
|
|
promethazine 25 mg Supp [VDMC]
|
Facility
|
IP
|
$21.51
|
|
|
Service Code
|
NDC 00713-0526-12
|
| Hospital Charge Code |
10416664
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.06 |
| Max. Negotiated Rate |
$19.36 |
| Rate for Payer: Aetna of IA Commercial |
$19.36
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.36
|
| Rate for Payer: Cash Price |
$17.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.13
|
| Rate for Payer: Medical Associates Commercial |
$16.13
|
| Rate for Payer: Midlands Choice Commercial |
$15.06
|
| Rate for Payer: United Healthcare Commercial |
$19.36
|
|
|
promethazine 25 mg Tab [VDMC]
|
Facility
|
OP
|
$1.63
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10416729
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| 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 |
$0.94
|
| Rate for Payer: Amerigroup Medicare |
$0.74
|
| 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 |
$0.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.93
|
| Rate for Payer: Medical Associates Commercial |
$1.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.73
|
| Rate for Payer: Midlands Choice Commercial |
$1.14
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.96
|
|
