|
THP benzonatate 100mg 5 capsules [VDMC]
|
Facility
|
IP
|
$10.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
26928388
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.13 |
| 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: Cash Price |
$8.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.64
|
| Rate for Payer: Medical Associates Commercial |
$7.64
|
| Rate for Payer: Midlands Choice Commercial |
$7.13
|
| Rate for Payer: United Healthcare Commercial |
$9.16
|
|
|
THP cefdinir 250 mg/5 mL Oral Susp 60ML [VDMC]
|
Facility
|
OP
|
$50.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10375249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.55 |
| Max. Negotiated Rate |
$45.11 |
| Rate for Payer: Aetna of IA Commercial |
$45.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.11
|
| Rate for Payer: Aetna of IA Medicare |
$28.57
|
| Rate for Payer: Amerigroup Medicaid |
$28.91
|
| Rate for Payer: Amerigroup Medicare |
$22.78
|
| Rate for Payer: Cash Price |
$40.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.59
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$28.63
|
| Rate for Payer: Medical Associates Commercial |
$37.59
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.55
|
| Rate for Payer: Midlands Choice Commercial |
$35.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$25.94
|
| Rate for Payer: United Healthcare Commercial |
$45.11
|
| Rate for Payer: United Healthcare Managed Medicare |
$29.57
|
|
|
THP cefdinir 250 mg/5 mL Oral Susp 60ML [VDMC]
|
Facility
|
IP
|
$50.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10375249
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$35.08 |
| Max. Negotiated Rate |
$45.11 |
| Rate for Payer: Aetna of IA Commercial |
$45.11
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$45.11
|
| Rate for Payer: Cash Price |
$40.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.59
|
| Rate for Payer: Medical Associates Commercial |
$37.59
|
| Rate for Payer: Midlands Choice Commercial |
$35.08
|
| Rate for Payer: United Healthcare Commercial |
$45.11
|
|
|
THP cefprozil 250 mg/5 mL 50ml Oral Liq [VDMC]
|
Facility
|
IP
|
$99.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10375793
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$69.66 |
| Max. Negotiated Rate |
$89.57 |
| Rate for Payer: Aetna of IA Commercial |
$89.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$89.57
|
| Rate for Payer: Cash Price |
$79.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.64
|
| Rate for Payer: Medical Associates Commercial |
$74.64
|
| Rate for Payer: Midlands Choice Commercial |
$69.66
|
| Rate for Payer: United Healthcare Commercial |
$89.57
|
|
|
THP cefprozil 250 mg/5 mL 50ml Oral Liq [VDMC]
|
Facility
|
OP
|
$99.52
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10375793
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$44.78 |
| Max. Negotiated Rate |
$89.57 |
| Rate for Payer: Aetna of IA Commercial |
$89.57
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$89.57
|
| Rate for Payer: Aetna of IA Medicare |
$56.73
|
| Rate for Payer: Amerigroup Medicaid |
$57.40
|
| Rate for Payer: Amerigroup Medicare |
$45.23
|
| Rate for Payer: Cash Price |
$79.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$44.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.85
|
| Rate for Payer: Medical Associates Commercial |
$74.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$44.78
|
| Rate for Payer: Midlands Choice Commercial |
$69.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$51.50
|
| Rate for Payer: United Healthcare Commercial |
$89.57
|
| Rate for Payer: United Healthcare Managed Medicare |
$58.72
|
|
|
THP Cefuroxime 250mg 3 tabs [VDMC]
|
Facility
|
IP
|
$21.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10736915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.35 |
| Max. Negotiated Rate |
$19.73 |
| Rate for Payer: Aetna of IA Commercial |
$19.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.73
|
| Rate for Payer: Cash Price |
$17.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.44
|
| Rate for Payer: Medical Associates Commercial |
$16.44
|
| Rate for Payer: Midlands Choice Commercial |
$15.35
|
| Rate for Payer: United Healthcare Commercial |
$19.73
|
|
|
THP Cefuroxime 250mg 3 tabs [VDMC]
|
Facility
|
OP
|
$21.92
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10736915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.86 |
| Max. Negotiated Rate |
$19.73 |
| Rate for Payer: Aetna of IA Commercial |
$19.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.73
|
| Rate for Payer: Aetna of IA Medicare |
$12.50
|
| Rate for Payer: Amerigroup Medicaid |
$12.64
|
| Rate for Payer: Amerigroup Medicare |
$9.96
|
| Rate for Payer: Cash Price |
$17.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.44
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.52
|
| Rate for Payer: Medical Associates Commercial |
$16.44
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.86
|
| Rate for Payer: Midlands Choice Commercial |
$15.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$11.34
|
| Rate for Payer: United Healthcare Commercial |
$19.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$12.93
|
|
|
THP Cephalexin 250mg/5ml 100ml Oral Susp Bottle [VDMC]
|
Facility
|
IP
|
$60.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14217797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$42.67 |
| Max. Negotiated Rate |
$54.86 |
| Rate for Payer: Aetna of IA Commercial |
$54.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.86
|
| Rate for Payer: Cash Price |
$48.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.72
|
| Rate for Payer: Medical Associates Commercial |
$45.72
|
| Rate for Payer: Midlands Choice Commercial |
$42.67
|
| Rate for Payer: United Healthcare Commercial |
$54.86
|
|
|
THP Cephalexin 250mg/5ml 100ml Oral Susp Bottle [VDMC]
|
Facility
|
OP
|
$60.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
14217797
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$54.86 |
| Rate for Payer: Aetna of IA Commercial |
$54.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.86
|
| Rate for Payer: Aetna of IA Medicare |
$34.75
|
| Rate for Payer: Amerigroup Medicaid |
$35.16
|
| Rate for Payer: Amerigroup Medicare |
$27.71
|
| Rate for Payer: Cash Price |
$48.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$34.82
|
| Rate for Payer: Medical Associates Commercial |
$45.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.43
|
| Rate for Payer: Midlands Choice Commercial |
$42.67
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.55
|
| Rate for Payer: United Healthcare Commercial |
$54.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.97
|
|
|
THP Cephalexin 500mg 6 capsules [VDMC]
|
Facility
|
IP
|
$12.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10737970
|
|
Hospital Revenue Code
|
259
|
| 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 Cephalexin 500mg 6 capsules [VDMC]
|
Facility
|
OP
|
$12.16
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10737970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.47 |
| 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 |
$7.01
|
| Rate for Payer: Amerigroup Medicare |
$5.53
|
| 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 |
$5.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.95
|
| Rate for Payer: Medical Associates Commercial |
$9.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.47
|
| Rate for Payer: Midlands Choice Commercial |
$8.51
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.29
|
| Rate for Payer: United Healthcare Commercial |
$10.94
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.17
|
|
|
THP Ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp 7.5 ml [VDMC]
|
Facility
|
OP
|
$488.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10378125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$220.03 |
| 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 |
$282.03
|
| Rate for Payer: Amerigroup Medicare |
$222.23
|
| 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 |
$220.03
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$279.29
|
| Rate for Payer: Medical Associates Commercial |
$366.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$220.03
|
| Rate for Payer: Midlands Choice Commercial |
$342.27
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$283.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$253.04
|
| Rate for Payer: United Healthcare Commercial |
$440.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$288.49
|
|
|
THP Ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp 7.5 ml [VDMC]
|
Facility
|
IP
|
$488.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10378125
|
|
Hospital Revenue Code
|
259
|
| 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 Clindamycin 150mg 6 capsules [VDMC]
|
Facility
|
IP
|
$13.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10738150
|
|
Hospital Revenue Code
|
259
|
| 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 Clindamycin 150mg 6 capsules [VDMC]
|
Facility
|
OP
|
$13.12
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10738150
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.90 |
| 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 |
$7.57
|
| Rate for Payer: Amerigroup Medicare |
$5.96
|
| 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 |
$5.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.49
|
| Rate for Payer: Medical Associates Commercial |
$9.84
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.90
|
| Rate for Payer: Midlands Choice Commercial |
$9.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.79
|
| Rate for Payer: United Healthcare Commercial |
$11.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.74
|
|
|
THP Cyclobenzaprine 10mg 4 tablets [VDMC]
|
Facility
|
OP
|
$10.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10738246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.80 |
| Rate for Payer: Aetna of IA Commercial |
$9.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.80
|
| Rate for Payer: Aetna of IA Medicare |
$6.20
|
| Rate for Payer: Amerigroup Medicaid |
$6.28
|
| Rate for Payer: Amerigroup Medicare |
$4.95
|
| 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 |
$4.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.22
|
| Rate for Payer: Medical Associates Commercial |
$8.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.90
|
| Rate for Payer: Midlands Choice Commercial |
$7.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.63
|
| Rate for Payer: United Healthcare Commercial |
$9.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.42
|
|
|
THP Cyclobenzaprine 10mg 4 tablets [VDMC]
|
Facility
|
IP
|
$10.88
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10738246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$9.80 |
| Rate for Payer: Aetna of IA Commercial |
$9.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$9.80
|
| 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 |
$9.80
|
|
|
THP Diazepam 5mg tab [VDMC]
|
Facility
|
IP
|
$10.45
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10738410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.31 |
| 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 |
$7.83
|
| Rate for Payer: Medical Associates Commercial |
$7.83
|
| Rate for Payer: Midlands Choice Commercial |
$7.31
|
| Rate for Payer: United Healthcare Commercial |
$9.40
|
|
|
THP Diazepam 5mg tab [VDMC]
|
Facility
|
OP
|
$10.45
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10738410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.70 |
| 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 |
$5.95
|
| Rate for Payer: Amerigroup Medicaid |
$6.03
|
| Rate for Payer: Amerigroup Medicare |
$4.75
|
| Rate for Payer: Cash Price |
$8.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.83
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.97
|
| Rate for Payer: Medical Associates Commercial |
$7.83
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.70
|
| Rate for Payer: Midlands Choice Commercial |
$7.31
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.41
|
| Rate for Payer: United Healthcare Commercial |
$9.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.16
|
|
|
THP Hydrocodone/APAP 5mg/325mg tab [VDMC]
|
Facility
|
IP
|
$11.14
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10740164
|
|
Hospital Revenue Code
|
259
|
| 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 Hydrocodone/APAP 5mg/325mg tab [VDMC]
|
Facility
|
OP
|
$11.14
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10740164
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.01 |
| 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 |
$6.43
|
| Rate for Payer: Amerigroup Medicare |
$5.06
|
| 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 |
$5.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.36
|
| Rate for Payer: Medical Associates Commercial |
$8.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.01
|
| Rate for Payer: Midlands Choice Commercial |
$7.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.77
|
| Rate for Payer: United Healthcare Commercial |
$10.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$6.57
|
|
|
THP Hydroxyzine 25mg tab [VDMC]
|
Facility
|
IP
|
$11.94
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10739255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$10.74 |
| Rate for Payer: Aetna of IA Commercial |
$10.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.74
|
| Rate for Payer: Cash Price |
$9.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.95
|
| Rate for Payer: Medical Associates Commercial |
$8.95
|
| Rate for Payer: Midlands Choice Commercial |
$8.36
|
| Rate for Payer: United Healthcare Commercial |
$10.74
|
|
|
THP Hydroxyzine 25mg tab [VDMC]
|
Facility
|
OP
|
$11.94
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10739255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$10.74 |
| Rate for Payer: Aetna of IA Commercial |
$10.74
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$10.74
|
| Rate for Payer: Aetna of IA Medicare |
$6.80
|
| Rate for Payer: Amerigroup Medicaid |
$6.89
|
| Rate for Payer: Amerigroup Medicare |
$5.43
|
| Rate for Payer: Cash Price |
$9.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$8.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$5.37
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.82
|
| Rate for Payer: Medical Associates Commercial |
$8.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$5.37
|
| Rate for Payer: Midlands Choice Commercial |
$8.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.18
|
| Rate for Payer: United Healthcare Commercial |
$10.74
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.04
|
|
|
THP levofloxacin 500 mg tab [VDMC]
|
Facility
|
OP
|
$14.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10729129
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.55 |
| 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 |
$8.40
|
| Rate for Payer: Amerigroup Medicare |
$6.62
|
| 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 |
$6.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.32
|
| Rate for Payer: Medical Associates Commercial |
$10.92
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.55
|
| Rate for Payer: Midlands Choice Commercial |
$10.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.53
|
| Rate for Payer: United Healthcare Commercial |
$13.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.59
|
|
|
THP levofloxacin 500 mg tab [VDMC]
|
Facility
|
IP
|
$14.56
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10729129
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
