|
THERMAL ENDOMETR TUMOR ABL
|
Professional
|
Both
|
$3,314.00
|
|
|
Service Code
|
CPT 58353
|
| Hospital Charge Code |
8069108
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$1,294.33 |
| Max. Negotiated Rate |
$2,485.50 |
| Rate for Payer: Amerigroup Medicaid |
$1,307.02
|
| Rate for Payer: Cash Price |
$2,651.20
|
| Rate for Payer: Cash Price |
$2,651.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,294.33
|
| Rate for Payer: Medical Associates Commercial |
$2,485.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,319.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,300.67
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,485.50
|
| Rate for Payer: United Healthcare Commercial |
$1,496.88
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,738.60
|
| Rate for Payer: Wellmark IA PPO |
$2,045.40
|
|
|
thiamine 100 mg/ml 2ml MDV Inj [VDMC]
|
Facility
|
OP
|
$32.51
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
10424876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$221.80 |
| Rate for Payer: Aetna of IA Commercial |
$29.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.26
|
| Rate for Payer: Aetna of IA Medicare |
$18.53
|
| Rate for Payer: Amerigroup Medicaid |
$18.75
|
| Rate for Payer: Amerigroup Medicare |
$14.78
|
| Rate for Payer: Cash Price |
$26.01
|
| Rate for Payer: Cash Price |
$26.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.57
|
| Rate for Payer: Medical Associates Commercial |
$24.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.63
|
| Rate for Payer: Midlands Choice Commercial |
$22.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.82
|
| Rate for Payer: United Healthcare Commercial |
$29.26
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.18
|
| Rate for Payer: Wellmark IA HMO WHPI |
$201.36
|
| Rate for Payer: Wellmark IA PPO |
$221.80
|
|
|
thiamine 100 mg/ml 2ml MDV Inj [VDMC]
|
Facility
|
IP
|
$32.51
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
10424876
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$29.26 |
| Rate for Payer: Aetna of IA Commercial |
$29.26
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$29.26
|
| Rate for Payer: Cash Price |
$26.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.38
|
| Rate for Payer: Medical Associates Commercial |
$24.38
|
| Rate for Payer: Midlands Choice Commercial |
$22.76
|
| Rate for Payer: United Healthcare Commercial |
$29.26
|
|
|
thiamine 100 mg Tab [VDMC]
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10424807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of IA Commercial |
$1.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.39
|
| Rate for Payer: Aetna of IA Medicare |
$0.88
|
| Rate for Payer: Amerigroup Medicaid |
$0.89
|
| Rate for Payer: Amerigroup Medicare |
$0.70
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.69
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.88
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.69
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.91
|
|
|
thiamine 100 mg Tab [VDMC]
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10424807
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of IA Commercial |
$1.39
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.39
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.15
|
| Rate for Payer: Medical Associates Commercial |
$1.15
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
|
|
THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE
|
Facility
|
OP
|
$1,640.88
|
|
|
Service Code
|
CPT 32554
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$1,489.61 |
| Max. Negotiated Rate |
$1,640.88 |
| Rate for Payer: Wellmark IA HMO WHPI |
$1,489.61
|
| Rate for Payer: Wellmark IA PPO |
$1,640.88
|
|
|
Thoracentesis Procedure
|
Facility
|
IP
|
$528.00
|
|
|
Service Code
|
CPT 32554
|
| Hospital Charge Code |
8060785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.60 |
| Max. Negotiated Rate |
$475.20 |
| Rate for Payer: Aetna of IA Commercial |
$475.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$475.20
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$396.00
|
| Rate for Payer: Medical Associates Commercial |
$396.00
|
| Rate for Payer: Midlands Choice Commercial |
$369.60
|
| Rate for Payer: United Healthcare Commercial |
$475.20
|
|
|
Thoracentesis Procedure
|
Facility
|
OP
|
$528.00
|
|
|
Service Code
|
CPT 32554
|
| Hospital Charge Code |
8060785
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$237.60 |
| Max. Negotiated Rate |
$1,640.88 |
| Rate for Payer: Aetna of IA Commercial |
$475.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$475.20
|
| Rate for Payer: Aetna of IA Medicare |
$300.96
|
| Rate for Payer: Amerigroup Medicaid |
$304.55
|
| Rate for Payer: Amerigroup Medicare |
$239.98
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$396.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$237.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$301.59
|
| Rate for Payer: Medical Associates Commercial |
$396.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$237.60
|
| Rate for Payer: Midlands Choice Commercial |
$369.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$306.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$273.24
|
| Rate for Payer: United Healthcare Commercial |
$475.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$311.52
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,489.61
|
| Rate for Payer: Wellmark IA PPO |
$1,640.88
|
|
|
THP Albuterol Inhaler [VDMC]
|
Facility
|
IP
|
$82.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10735590
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$58.02 |
| Max. Negotiated Rate |
$74.59 |
| Rate for Payer: Aetna of IA Commercial |
$74.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$74.59
|
| Rate for Payer: Cash Price |
$66.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$62.16
|
| Rate for Payer: Medical Associates Commercial |
$62.16
|
| Rate for Payer: Midlands Choice Commercial |
$58.02
|
| Rate for Payer: United Healthcare Commercial |
$74.59
|
|
|
THP Albuterol Inhaler [VDMC]
|
Facility
|
OP
|
$82.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10735590
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$37.30 |
| Max. Negotiated Rate |
$74.59 |
| Rate for Payer: Aetna of IA Commercial |
$74.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$74.59
|
| Rate for Payer: Aetna of IA Medicare |
$47.24
|
| Rate for Payer: Amerigroup Medicaid |
$47.81
|
| Rate for Payer: Amerigroup Medicare |
$37.67
|
| Rate for Payer: Cash Price |
$66.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$62.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$37.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$47.34
|
| Rate for Payer: Medical Associates Commercial |
$62.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$37.30
|
| Rate for Payer: Midlands Choice Commercial |
$58.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$48.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$42.89
|
| Rate for Payer: United Healthcare Commercial |
$74.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$48.90
|
|
|
THP albuterol-ipratropium 0.5mg/3mg neb sol 3mL SDV [VDMC]
|
Facility
|
OP
|
$10.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
26928539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$9.29 |
| Rate for Payer: Aetna of IA Commercial |
$9.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.29
|
| Rate for Payer: Aetna of IA Medicare |
$5.88
|
| Rate for Payer: Amerigroup Medicaid |
$5.95
|
| Rate for Payer: Amerigroup Medicare |
$4.69
|
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.74
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.90
|
| Rate for Payer: Medical Associates Commercial |
$7.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.65
|
| Rate for Payer: Midlands Choice Commercial |
$7.23
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.34
|
| Rate for Payer: United Healthcare Commercial |
$9.29
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.09
|
|
|
THP albuterol-ipratropium 0.5mg/3mg neb sol 3mL SDV [VDMC]
|
Facility
|
IP
|
$10.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
26928539
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$9.29 |
| Rate for Payer: Aetna of IA Commercial |
$9.29
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.29
|
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.74
|
| Rate for Payer: Medical Associates Commercial |
$7.74
|
| Rate for Payer: Midlands Choice Commercial |
$7.23
|
| Rate for Payer: United Healthcare Commercial |
$9.29
|
|
|
THP amoxicillin 400 mg/5 mL Oral Liq 50ml [VDMC]
|
Facility
|
IP
|
$22.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.62 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna of IA Commercial |
$20.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.09
|
| Rate for Payer: Cash Price |
$17.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.74
|
| Rate for Payer: Medical Associates Commercial |
$16.74
|
| Rate for Payer: Midlands Choice Commercial |
$15.62
|
| Rate for Payer: United Healthcare Commercial |
$20.09
|
|
|
THP amoxicillin 400 mg/5 mL Oral Liq 50ml [VDMC]
|
Facility
|
OP
|
$22.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366522
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna of IA Commercial |
$20.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.09
|
| Rate for Payer: Aetna of IA Medicare |
$12.72
|
| Rate for Payer: Amerigroup Medicaid |
$12.87
|
| Rate for Payer: Amerigroup Medicare |
$10.14
|
| Rate for Payer: Cash Price |
$17.86
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.74
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$10.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.75
|
| Rate for Payer: Medical Associates Commercial |
$16.74
|
| Rate for Payer: Medical Associates Managed Medicare |
$10.04
|
| Rate for Payer: Midlands Choice Commercial |
$15.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.55
|
| Rate for Payer: United Healthcare Commercial |
$20.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.17
|
|
|
THP Amoxicillin 500mg 6 capsules [VDMC]
|
Facility
|
OP
|
$12.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10735809
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.69 |
| Max. Negotiated Rate |
$11.38 |
| Rate for Payer: Aetna of IA Commercial |
$11.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.38
|
| Rate for Payer: Aetna of IA Medicare |
$7.20
|
| Rate for Payer: Amerigroup Medicaid |
$7.29
|
| Rate for Payer: Amerigroup Medicare |
$5.74
|
| Rate for Payer: Cash Price |
$10.11
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.48
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.69
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.22
|
| Rate for Payer: Medical Associates Commercial |
$9.48
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.69
|
| Rate for Payer: Midlands Choice Commercial |
$8.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.54
|
| Rate for Payer: United Healthcare Commercial |
$11.38
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.46
|
|
|
THP Amoxicillin 500mg 6 capsules [VDMC]
|
Facility
|
IP
|
$12.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10735809
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$11.38 |
| Rate for Payer: Aetna of IA Commercial |
$11.38
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.38
|
| Rate for Payer: Cash Price |
$10.11
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.48
|
| Rate for Payer: Medical Associates Commercial |
$9.48
|
| Rate for Payer: Midlands Choice Commercial |
$8.85
|
| Rate for Payer: United Healthcare Commercial |
$11.38
|
|
|
THP amoxicillin-clavulanate 250 mg-62.5 mg/5 mL Oral Liq 75 ml[VDMC]
|
Facility
|
IP
|
$186.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366591
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$130.59 |
| Max. Negotiated Rate |
$167.90 |
| Rate for Payer: Aetna of IA Commercial |
$167.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$167.90
|
| Rate for Payer: Cash Price |
$149.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$139.92
|
| Rate for Payer: Medical Associates Commercial |
$139.92
|
| Rate for Payer: Midlands Choice Commercial |
$130.59
|
| Rate for Payer: United Healthcare Commercial |
$167.90
|
|
|
THP amoxicillin-clavulanate 250 mg-62.5 mg/5 mL Oral Liq 75 ml[VDMC]
|
Facility
|
OP
|
$186.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10366591
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$83.95 |
| Max. Negotiated Rate |
$167.90 |
| Rate for Payer: Aetna of IA Commercial |
$167.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$167.90
|
| Rate for Payer: Aetna of IA Medicare |
$106.34
|
| Rate for Payer: Amerigroup Medicaid |
$107.61
|
| Rate for Payer: Amerigroup Medicare |
$84.79
|
| Rate for Payer: Cash Price |
$149.25
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$139.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$83.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$106.56
|
| Rate for Payer: Medical Associates Commercial |
$139.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$83.95
|
| Rate for Payer: Midlands Choice Commercial |
$130.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$108.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$96.54
|
| Rate for Payer: United Healthcare Commercial |
$167.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$110.07
|
|
|
THP Amoxicillin Clavulanate 875mg/125mg 6 tablets [VDMC]
|
Facility
|
OP
|
$21.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10736392
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$19.37 |
| Rate for Payer: Aetna of IA Commercial |
$19.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.37
|
| Rate for Payer: Aetna of IA Medicare |
$12.27
|
| Rate for Payer: Amerigroup Medicaid |
$12.41
|
| Rate for Payer: Amerigroup Medicare |
$9.78
|
| Rate for Payer: Cash Price |
$17.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.14
|
| 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 |
$16.14
|
| 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 |
$11.14
|
| Rate for Payer: United Healthcare Commercial |
$19.37
|
| Rate for Payer: United Healthcare Managed Medicare |
$12.70
|
|
|
THP Amoxicillin Clavulanate 875mg/125mg 6 tablets [VDMC]
|
Facility
|
IP
|
$21.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10736392
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.06 |
| Max. Negotiated Rate |
$19.37 |
| Rate for Payer: Aetna of IA Commercial |
$19.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.37
|
| Rate for Payer: Cash Price |
$17.22
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.14
|
| Rate for Payer: Medical Associates Commercial |
$16.14
|
| Rate for Payer: Midlands Choice Commercial |
$15.06
|
| Rate for Payer: United Healthcare Commercial |
$19.37
|
|
|
THP Azithromycin 200mg/5ml 15ml Susp [VDMC]
|
Facility
|
IP
|
$66.60
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14364642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$46.62 |
| Max. Negotiated Rate |
$59.94 |
| Rate for Payer: Aetna of IA Commercial |
$59.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.94
|
| Rate for Payer: Cash Price |
$53.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.95
|
| Rate for Payer: Medical Associates Commercial |
$49.95
|
| Rate for Payer: Midlands Choice Commercial |
$46.62
|
| Rate for Payer: United Healthcare Commercial |
$59.94
|
|
|
THP Azithromycin 200mg/5ml 15ml Susp [VDMC]
|
Facility
|
OP
|
$66.60
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14364642
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.97 |
| Max. Negotiated Rate |
$59.94 |
| Rate for Payer: Aetna of IA Commercial |
$59.94
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.94
|
| Rate for Payer: Aetna of IA Medicare |
$37.96
|
| Rate for Payer: Amerigroup Medicaid |
$38.41
|
| Rate for Payer: Amerigroup Medicare |
$30.27
|
| Rate for Payer: Cash Price |
$53.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$38.04
|
| Rate for Payer: Medical Associates Commercial |
$49.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.97
|
| Rate for Payer: Midlands Choice Commercial |
$46.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$34.47
|
| Rate for Payer: United Healthcare Commercial |
$59.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.29
|
|
|
THP Azithromycin 250mg 3 tablets [VDMC]
|
Facility
|
OP
|
$21.62
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10736680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.73 |
| Max. Negotiated Rate |
$19.45 |
| Rate for Payer: Aetna of IA Commercial |
$19.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.45
|
| Rate for Payer: Aetna of IA Medicare |
$12.32
|
| Rate for Payer: Amerigroup Medicaid |
$12.47
|
| Rate for Payer: Amerigroup Medicare |
$9.82
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.21
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.35
|
| Rate for Payer: Medical Associates Commercial |
$16.21
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.73
|
| Rate for Payer: Midlands Choice Commercial |
$15.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.19
|
| Rate for Payer: United Healthcare Commercial |
$19.45
|
| Rate for Payer: United Healthcare Managed Medicare |
$12.75
|
|
|
THP Azithromycin 250mg 3 tablets [VDMC]
|
Facility
|
IP
|
$21.62
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10736680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.13 |
| Max. Negotiated Rate |
$19.45 |
| Rate for Payer: Aetna of IA Commercial |
$19.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.45
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.21
|
| Rate for Payer: Medical Associates Commercial |
$16.21
|
| Rate for Payer: Midlands Choice Commercial |
$15.13
|
| Rate for Payer: United Healthcare Commercial |
$19.45
|
|
|
THP benzonatate 100mg 5 capsules [VDMC]
|
Facility
|
OP
|
$10.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
26928388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$9.16 |
| Rate for Payer: Aetna of IA Commercial |
$9.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.16
|
| Rate for Payer: Aetna of IA Medicare |
$5.80
|
| Rate for Payer: Amerigroup Medicaid |
$5.87
|
| Rate for Payer: Amerigroup Medicare |
$4.63
|
| Rate for Payer: Cash Price |
$8.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.82
|
| Rate for Payer: Medical Associates Commercial |
$7.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.58
|
| Rate for Payer: Midlands Choice Commercial |
$7.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.27
|
| Rate for Payer: United Healthcare Commercial |
$9.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.01
|
|
