|
THP Cephalexin 500mg 6 capsules
|
Facility
OP
|
$12.16
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna of IA Commercial |
$10.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.94
|
| Rate for Payer: Aetna of IA Medicare |
$6.93
|
| Rate for Payer: Amerigroup Medicaid |
$6.14
|
| Rate for Payer: Amerigroup Medicare |
$6.14
|
| Rate for Payer: Cash Price |
$9.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.08
|
| Rate for Payer: Medical Associates Commercial |
$9.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.08
|
| Rate for Payer: Midlands Choice Commercial |
$8.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.12
|
| Rate for Payer: United Healthcare Commercial |
$10.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.17
|
|
|
THP Cephalexin 500mg 6 capsules
|
Facility
IP
|
$12.16
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna of IA Commercial |
$10.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.94
|
| Rate for Payer: Cash Price |
$9.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.12
|
| Rate for Payer: Medical Associates Commercial |
$9.12
|
| Rate for Payer: Midlands Choice Commercial |
$8.51
|
| Rate for Payer: United Healthcare Commercial |
$10.94
|
|
|
THP Ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp 7.5 ml
|
Facility
IP
|
$488.96
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43766145
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$342.27 |
| Max. Negotiated Rate |
$440.06 |
| Rate for Payer: Aetna of IA Commercial |
$440.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$440.06
|
| Rate for Payer: Cash Price |
$391.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$366.72
|
| Rate for Payer: Medical Associates Commercial |
$366.72
|
| Rate for Payer: Midlands Choice Commercial |
$342.27
|
| Rate for Payer: United Healthcare Commercial |
$440.06
|
|
|
THP Ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp 7.5 ml
|
Facility
OP
|
$488.96
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43766145
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$244.38 |
| Max. Negotiated Rate |
$440.06 |
| Rate for Payer: Aetna of IA Commercial |
$440.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$440.06
|
| Rate for Payer: Aetna of IA Medicare |
$278.71
|
| Rate for Payer: Amerigroup Medicaid |
$246.78
|
| Rate for Payer: Amerigroup Medicare |
$246.92
|
| Rate for Payer: Cash Price |
$391.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$366.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$244.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$244.38
|
| Rate for Payer: Medical Associates Commercial |
$366.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$244.48
|
| Rate for Payer: Midlands Choice Commercial |
$342.27
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$248.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$366.72
|
| Rate for Payer: United Healthcare Commercial |
$440.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$288.49
|
|
|
THP Clindamycin 150mg 6 capsules
|
Facility
OP
|
$13.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43721839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.56 |
| Max. Negotiated Rate |
$11.81 |
| Rate for Payer: Aetna of IA Commercial |
$11.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.81
|
| Rate for Payer: Aetna of IA Medicare |
$7.48
|
| Rate for Payer: Amerigroup Medicaid |
$6.62
|
| Rate for Payer: Amerigroup Medicare |
$6.63
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.56
|
| Rate for Payer: Medical Associates Commercial |
$9.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.56
|
| Rate for Payer: Midlands Choice Commercial |
$9.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.84
|
| Rate for Payer: United Healthcare Commercial |
$11.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.74
|
|
|
THP Clindamycin 150mg 6 capsules
|
Facility
IP
|
$13.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43721839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$11.81 |
| Rate for Payer: Aetna of IA Commercial |
$11.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.81
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.84
|
| Rate for Payer: Medical Associates Commercial |
$9.84
|
| Rate for Payer: Midlands Choice Commercial |
$9.18
|
| Rate for Payer: United Healthcare Commercial |
$11.81
|
|
|
THP Cyclobenzaprine 10mg 4 tablets
|
Facility
OP
|
$10.88
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43781283
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.44 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna of IA Commercial |
$9.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.79
|
| Rate for Payer: Aetna of IA Medicare |
$6.20
|
| Rate for Payer: Amerigroup Medicaid |
$5.49
|
| Rate for Payer: Amerigroup Medicare |
$5.49
|
| Rate for Payer: Cash Price |
$8.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.44
|
| Rate for Payer: Medical Associates Commercial |
$8.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.44
|
| Rate for Payer: Midlands Choice Commercial |
$7.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.16
|
| Rate for Payer: United Healthcare Commercial |
$9.79
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.42
|
|
|
THP Cyclobenzaprine 10mg 4 tablets
|
Facility
IP
|
$10.88
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43781283
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna of IA Commercial |
$9.79
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.79
|
| Rate for Payer: Cash Price |
$8.71
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.16
|
| Rate for Payer: Medical Associates Commercial |
$8.16
|
| Rate for Payer: Midlands Choice Commercial |
$7.62
|
| Rate for Payer: United Healthcare Commercial |
$9.79
|
|
|
THP Diazepam 5mg tab
|
Facility
OP
|
$10.45
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43751002
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$9.40 |
| Rate for Payer: Aetna of IA Commercial |
$9.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.40
|
| Rate for Payer: Aetna of IA Medicare |
$5.96
|
| Rate for Payer: Amerigroup Medicaid |
$5.27
|
| Rate for Payer: Amerigroup Medicare |
$5.28
|
| Rate for Payer: Cash Price |
$8.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.84
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.22
|
| Rate for Payer: Medical Associates Commercial |
$7.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.22
|
| Rate for Payer: Midlands Choice Commercial |
$7.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.84
|
| Rate for Payer: United Healthcare Commercial |
$9.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.17
|
|
|
THP Diazepam 5mg tab
|
Facility
IP
|
$10.45
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43751002
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.32 |
| Max. Negotiated Rate |
$9.40 |
| Rate for Payer: Aetna of IA Commercial |
$9.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.40
|
| Rate for Payer: Cash Price |
$8.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.84
|
| Rate for Payer: Medical Associates Commercial |
$7.84
|
| Rate for Payer: Midlands Choice Commercial |
$7.32
|
| Rate for Payer: United Healthcare Commercial |
$9.40
|
|
|
THP Hydrocodone/APAP 5mg/325mg tab
|
Facility
OP
|
$11.14
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43723719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Aetna of IA Commercial |
$10.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.03
|
| Rate for Payer: Aetna of IA Medicare |
$6.35
|
| Rate for Payer: Amerigroup Medicaid |
$5.62
|
| Rate for Payer: Amerigroup Medicare |
$5.63
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.57
|
| Rate for Payer: Medical Associates Commercial |
$8.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.57
|
| Rate for Payer: Midlands Choice Commercial |
$7.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.36
|
| Rate for Payer: United Healthcare Commercial |
$10.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.57
|
|
|
THP Hydrocodone/APAP 5mg/325mg tab
|
Facility
IP
|
$11.14
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43723719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Aetna of IA Commercial |
$10.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.03
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.36
|
| Rate for Payer: Medical Associates Commercial |
$8.36
|
| Rate for Payer: Midlands Choice Commercial |
$7.80
|
| Rate for Payer: United Healthcare Commercial |
$10.03
|
|
|
THP Hydroxyzine 25mg tab
|
Facility
IP
|
$11.94
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43750099
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$10.75 |
| Rate for Payer: Aetna of IA Commercial |
$10.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.75
|
| Rate for Payer: Cash Price |
$9.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.96
|
| Rate for Payer: Medical Associates Commercial |
$8.96
|
| Rate for Payer: Midlands Choice Commercial |
$8.36
|
| Rate for Payer: United Healthcare Commercial |
$10.75
|
|
|
THP Hydroxyzine 25mg tab
|
Facility
OP
|
$11.94
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43750099
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$5.97 |
| Max. Negotiated Rate |
$10.75 |
| Rate for Payer: Aetna of IA Commercial |
$10.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.75
|
| Rate for Payer: Aetna of IA Medicare |
$6.81
|
| Rate for Payer: Amerigroup Medicaid |
$6.03
|
| Rate for Payer: Amerigroup Medicare |
$6.03
|
| Rate for Payer: Cash Price |
$9.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.96
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.97
|
| Rate for Payer: Medical Associates Commercial |
$8.96
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.97
|
| Rate for Payer: Midlands Choice Commercial |
$8.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$8.96
|
| Rate for Payer: United Healthcare Commercial |
$10.75
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.04
|
|
|
THP levofloxacin 500 mg tab
|
Facility
IP
|
$14.56
|
|
|
Service Code
|
CPT J7509
|
| Hospital Charge Code |
43705955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$13.10 |
| Rate for Payer: Aetna of IA Commercial |
$13.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.10
|
| Rate for Payer: Cash Price |
$11.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.92
|
| Rate for Payer: Medical Associates Commercial |
$10.92
|
| Rate for Payer: Midlands Choice Commercial |
$10.19
|
| Rate for Payer: United Healthcare Commercial |
$13.10
|
|
|
THP levofloxacin 500 mg tab
|
Facility
OP
|
$14.56
|
|
|
Service Code
|
CPT J7509
|
| Hospital Charge Code |
43705955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$13.10 |
| Rate for Payer: Aetna of IA Commercial |
$13.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.10
|
| Rate for Payer: Aetna of IA Medicare |
$8.30
|
| Rate for Payer: Amerigroup Medicaid |
$7.35
|
| Rate for Payer: Amerigroup Medicare |
$7.35
|
| Rate for Payer: Cash Price |
$11.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.28
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.28
|
| Rate for Payer: Medical Associates Commercial |
$10.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.28
|
| Rate for Payer: Midlands Choice Commercial |
$10.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.92
|
| Rate for Payer: United Healthcare Commercial |
$13.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.59
|
|
|
THP methylPREDNISolone 4 mg Tab
|
Facility
OP
|
$76.28
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43756761
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.12 |
| Max. Negotiated Rate |
$68.65 |
| Rate for Payer: Aetna of IA Commercial |
$68.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.65
|
| Rate for Payer: Aetna of IA Medicare |
$43.48
|
| Rate for Payer: Amerigroup Medicaid |
$38.50
|
| Rate for Payer: Amerigroup Medicare |
$38.52
|
| Rate for Payer: Cash Price |
$61.02
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.21
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$38.14
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.12
|
| Rate for Payer: Medical Associates Commercial |
$57.21
|
| Rate for Payer: Medical Associates Managed Medicare |
$38.14
|
| Rate for Payer: Midlands Choice Commercial |
$53.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$57.21
|
| Rate for Payer: United Healthcare Commercial |
$68.65
|
| Rate for Payer: United Healthcare Managed Medicare |
$45.01
|
|
|
THP methylPREDNISolone 4 mg Tab
|
Facility
IP
|
$76.28
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43756761
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.40 |
| Max. Negotiated Rate |
$68.65 |
| Rate for Payer: Aetna of IA Commercial |
$68.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.65
|
| Rate for Payer: Cash Price |
$61.02
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$57.21
|
| Rate for Payer: Medical Associates Commercial |
$57.21
|
| Rate for Payer: Midlands Choice Commercial |
$53.40
|
| Rate for Payer: United Healthcare Commercial |
$68.65
|
|
|
THP nitrofurantoin 50 mg cap
|
Facility
OP
|
$22.96
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.48 |
| Max. Negotiated Rate |
$20.66 |
| Rate for Payer: Aetna of IA Commercial |
$20.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.66
|
| Rate for Payer: Aetna of IA Medicare |
$13.09
|
| Rate for Payer: Amerigroup Medicaid |
$11.59
|
| Rate for Payer: Amerigroup Medicare |
$11.59
|
| Rate for Payer: Cash Price |
$18.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.48
|
| Rate for Payer: Medical Associates Commercial |
$17.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.48
|
| Rate for Payer: Midlands Choice Commercial |
$16.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.22
|
| Rate for Payer: United Healthcare Commercial |
$20.66
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.55
|
|
|
THP nitrofurantoin 50 mg cap
|
Facility
IP
|
$22.96
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$20.66 |
| Rate for Payer: Aetna of IA Commercial |
$20.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.66
|
| Rate for Payer: Cash Price |
$18.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.22
|
| Rate for Payer: Medical Associates Commercial |
$17.22
|
| Rate for Payer: Midlands Choice Commercial |
$16.07
|
| Rate for Payer: United Healthcare Commercial |
$20.66
|
|
|
THP ondansetron 4 mg tab-DIS 5 Tablets
|
Facility
IP
|
$13.80
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43761287
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$12.42 |
| Rate for Payer: Aetna of IA Commercial |
$12.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.42
|
| Rate for Payer: Cash Price |
$11.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.35
|
| Rate for Payer: Medical Associates Commercial |
$10.35
|
| Rate for Payer: Midlands Choice Commercial |
$9.66
|
| Rate for Payer: United Healthcare Commercial |
$12.42
|
|
|
THP ondansetron 4 mg tab-DIS 5 Tablets
|
Facility
OP
|
$13.80
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43761287
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$12.42 |
| Rate for Payer: Aetna of IA Commercial |
$12.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.42
|
| Rate for Payer: Aetna of IA Medicare |
$7.87
|
| Rate for Payer: Amerigroup Medicaid |
$6.96
|
| Rate for Payer: Amerigroup Medicare |
$6.97
|
| Rate for Payer: Cash Price |
$11.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.90
|
| Rate for Payer: Medical Associates Commercial |
$10.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.90
|
| Rate for Payer: Midlands Choice Commercial |
$9.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.35
|
| Rate for Payer: United Healthcare Commercial |
$12.42
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.14
|
|
|
THP oxycodone/APAP 5 mg/325 mg 5 tablets
|
Facility
IP
|
$14.75
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43720911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$13.28 |
| Rate for Payer: Aetna of IA Commercial |
$13.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.28
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.06
|
| Rate for Payer: Medical Associates Commercial |
$11.06
|
| Rate for Payer: Midlands Choice Commercial |
$10.32
|
| Rate for Payer: United Healthcare Commercial |
$13.28
|
|
|
THP oxycodone/APAP 5 mg/325 mg 5 tablets
|
Facility
OP
|
$14.75
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43720911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$13.28 |
| Rate for Payer: Aetna of IA Commercial |
$13.28
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$13.28
|
| Rate for Payer: Aetna of IA Medicare |
$8.41
|
| Rate for Payer: Amerigroup Medicaid |
$7.44
|
| Rate for Payer: Amerigroup Medicare |
$7.45
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$11.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.37
|
| Rate for Payer: Medical Associates Commercial |
$11.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.38
|
| Rate for Payer: Midlands Choice Commercial |
$10.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.49
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.06
|
| Rate for Payer: United Healthcare Commercial |
$13.28
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.70
|
|
|
THP phenazopyridine 200 mg 6 tabs
|
Facility
OP
|
$18.40
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43740173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.20 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna of IA Commercial |
$16.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.56
|
| Rate for Payer: Aetna of IA Medicare |
$10.49
|
| Rate for Payer: Amerigroup Medicaid |
$9.29
|
| Rate for Payer: Amerigroup Medicare |
$9.29
|
| Rate for Payer: Cash Price |
$14.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.20
|
| Rate for Payer: Medical Associates Commercial |
$13.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.20
|
| Rate for Payer: Midlands Choice Commercial |
$12.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.80
|
| Rate for Payer: United Healthcare Commercial |
$16.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.86
|
|
