|
HUMERAL STEM 11MM X 151MM
|
Facility
OP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047270
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,306.18 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,770.55
|
| Rate for Payer: Amerigroup Medicaid |
$3,338.59
|
| Rate for Payer: Amerigroup Medicare |
$3,340.58
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,307.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,306.18
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,307.50
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,357.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,961.25
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,902.85
|
|
|
HUMERAL STEM 11MM X 151MM
|
Facility
IP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047270
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,630.50 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
|
|
HUMERAL STEM 12MM X 151MM
|
Facility
IP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047271
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,630.50 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
|
|
HUMERAL STEM 12MM X 151MM
|
Facility
OP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047271
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,306.18 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,770.55
|
| Rate for Payer: Amerigroup Medicaid |
$3,338.59
|
| Rate for Payer: Amerigroup Medicare |
$3,340.58
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,307.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,306.18
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,307.50
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,357.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,961.25
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,902.85
|
|
|
HUMERAL STEM 6MM X 115MM
|
Facility
IP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,630.50 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
|
|
HUMERAL STEM 6MM X 115MM
|
Facility
OP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,306.18 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,770.55
|
| Rate for Payer: Amerigroup Medicaid |
$3,338.59
|
| Rate for Payer: Amerigroup Medicare |
$3,340.58
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,307.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,306.18
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,307.50
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,357.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,961.25
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,902.85
|
|
|
HUMERAL STEM 7MM X 140MM
|
Facility
IP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047266
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,630.50 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
|
|
HUMERAL STEM 7MM X 140MM
|
Facility
OP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047266
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,306.18 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,770.55
|
| Rate for Payer: Amerigroup Medicaid |
$3,338.59
|
| Rate for Payer: Amerigroup Medicare |
$3,340.58
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,307.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,306.18
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,307.50
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,357.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,961.25
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,902.85
|
|
|
HUMERAL STEM 8MM X 143MM
|
Facility
OP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047267
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,306.18 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,770.55
|
| Rate for Payer: Amerigroup Medicaid |
$3,338.59
|
| Rate for Payer: Amerigroup Medicare |
$3,340.58
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,307.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,306.18
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,307.50
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,357.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,961.25
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,902.85
|
|
|
HUMERAL STEM 8MM X 143MM
|
Facility
IP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047267
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,630.50 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
|
|
HUMERAL STEM 9MM X 146MM
|
Facility
IP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,630.50 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
|
|
HUMERAL STEM 9MM X 146MM
|
Facility
OP
|
$6,615.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047268
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,306.18 |
| Max. Negotiated Rate |
$5,953.50 |
| Rate for Payer: Aetna of IA Commercial |
$5,953.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5,953.50
|
| Rate for Payer: Aetna of IA Medicare |
$3,770.55
|
| Rate for Payer: Amerigroup Medicaid |
$3,338.59
|
| Rate for Payer: Amerigroup Medicare |
$3,340.58
|
| Rate for Payer: Cash Price |
$5,292.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4,961.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3,307.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,306.18
|
| Rate for Payer: Medical Associates Commercial |
$4,961.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$3,307.50
|
| Rate for Payer: Midlands Choice Commercial |
$4,630.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,357.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$4,961.25
|
| Rate for Payer: United Healthcare Commercial |
$5,953.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,902.85
|
|
|
HUMERAL STEM CEMENTED
|
Facility
OP
|
$5,148.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047293
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,572.97 |
| Max. Negotiated Rate |
$4,633.20 |
| Rate for Payer: Aetna of IA Commercial |
$4,633.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,633.20
|
| Rate for Payer: Aetna of IA Medicare |
$2,934.36
|
| Rate for Payer: Amerigroup Medicaid |
$2,598.20
|
| Rate for Payer: Amerigroup Medicare |
$2,599.74
|
| Rate for Payer: Cash Price |
$4,118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,861.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,574.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,572.97
|
| Rate for Payer: Medical Associates Commercial |
$3,861.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,574.00
|
| Rate for Payer: Midlands Choice Commercial |
$3,603.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,612.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,861.00
|
| Rate for Payer: United Healthcare Commercial |
$4,633.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$3,037.32
|
|
|
HUMERAL STEM CEMENTED
|
Facility
IP
|
$5,148.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
8047293
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,603.60 |
| Max. Negotiated Rate |
$4,633.20 |
| Rate for Payer: Aetna of IA Commercial |
$4,633.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4,633.20
|
| Rate for Payer: Cash Price |
$4,118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,861.00
|
| Rate for Payer: Medical Associates Commercial |
$3,861.00
|
| Rate for Payer: Midlands Choice Commercial |
$3,603.60
|
| Rate for Payer: United Healthcare Commercial |
$4,633.20
|
|
|
hyaluronidase 150 units/mL 1ml inj
|
Facility
IP
|
$209.53
|
|
|
Service Code
|
CPT J3473
|
| Hospital Charge Code |
43700261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.67 |
| Max. Negotiated Rate |
$188.58 |
| Rate for Payer: Aetna of IA Commercial |
$188.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$188.58
|
| Rate for Payer: Cash Price |
$167.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$157.15
|
| Rate for Payer: Medical Associates Commercial |
$157.15
|
| Rate for Payer: Midlands Choice Commercial |
$146.67
|
| Rate for Payer: United Healthcare Commercial |
$188.58
|
|
|
hyaluronidase 150 units/mL 1ml inj
|
Facility
OP
|
$209.53
|
|
|
Service Code
|
CPT J3473
|
| Hospital Charge Code |
43700261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.72 |
| Max. Negotiated Rate |
$188.58 |
| Rate for Payer: Aetna of IA Commercial |
$188.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$188.58
|
| Rate for Payer: Aetna of IA Medicare |
$119.43
|
| Rate for Payer: Amerigroup Medicaid |
$105.75
|
| Rate for Payer: Amerigroup Medicare |
$105.81
|
| Rate for Payer: Cash Price |
$167.62
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$157.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$104.76
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$104.72
|
| Rate for Payer: Medical Associates Commercial |
$157.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$104.76
|
| Rate for Payer: Midlands Choice Commercial |
$146.67
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$106.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$157.15
|
| Rate for Payer: United Healthcare Commercial |
$188.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$123.62
|
|
|
hydrALAZINE 10 mg Tab
|
Facility
IP
|
$1.41
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702498
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna of IA Commercial |
$1.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.27
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.06
|
| Rate for Payer: Medical Associates Commercial |
$1.06
|
| Rate for Payer: Midlands Choice Commercial |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$1.27
|
|
|
hydrALAZINE 10 mg Tab
|
Facility
OP
|
$1.41
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702498
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna of IA Commercial |
$1.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.27
|
| Rate for Payer: Aetna of IA Medicare |
$0.80
|
| Rate for Payer: Amerigroup Medicaid |
$0.71
|
| Rate for Payer: Amerigroup Medicare |
$0.71
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.71
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.70
|
| Rate for Payer: Medical Associates Commercial |
$1.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.71
|
| Rate for Payer: Midlands Choice Commercial |
$0.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.06
|
| Rate for Payer: United Healthcare Commercial |
$1.27
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.83
|
|
|
hydrALAZINE 20 mg/mL SDV Inj Sol
|
Facility
OP
|
$27.22
|
|
|
Service Code
|
CPT J0360
|
| Hospital Charge Code |
43701754
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$24.50 |
| Rate for Payer: Aetna of IA Commercial |
$24.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.50
|
| Rate for Payer: Aetna of IA Medicare |
$15.52
|
| Rate for Payer: Amerigroup Medicaid |
$13.74
|
| Rate for Payer: Amerigroup Medicare |
$13.75
|
| Rate for Payer: Cash Price |
$21.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.42
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.60
|
| Rate for Payer: Medical Associates Commercial |
$20.42
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.61
|
| Rate for Payer: Midlands Choice Commercial |
$19.05
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.42
|
| Rate for Payer: United Healthcare Commercial |
$24.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.06
|
|
|
hydrALAZINE 20 mg/mL SDV Inj Sol
|
Facility
IP
|
$27.22
|
|
|
Service Code
|
CPT J0360
|
| Hospital Charge Code |
43701754
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.05 |
| Max. Negotiated Rate |
$24.50 |
| Rate for Payer: Aetna of IA Commercial |
$24.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.50
|
| Rate for Payer: Cash Price |
$21.78
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.42
|
| Rate for Payer: Medical Associates Commercial |
$20.42
|
| Rate for Payer: Midlands Choice Commercial |
$19.05
|
| Rate for Payer: United Healthcare Commercial |
$24.50
|
|
|
hydrALAZINE 25 mg Tab
|
Facility
OP
|
$1.34
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of IA Commercial |
$1.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.21
|
| Rate for Payer: Aetna of IA Medicare |
$0.76
|
| Rate for Payer: Amerigroup Medicaid |
$0.68
|
| Rate for Payer: Amerigroup Medicare |
$0.68
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.67
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.67
|
| Rate for Payer: Midlands Choice Commercial |
$0.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.68
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.79
|
|
|
hydrALAZINE 25 mg Tab
|
Facility
IP
|
$1.34
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna of IA Commercial |
$1.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.21
|
| Rate for Payer: Cash Price |
$1.07
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.00
|
| Rate for Payer: Medical Associates Commercial |
$1.00
|
| Rate for Payer: Midlands Choice Commercial |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.21
|
|
|
hydrochlorothiazide 25 mg Tab
|
Facility
OP
|
$1.07
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of IA Commercial |
$0.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.96
|
| Rate for Payer: Aetna of IA Medicare |
$0.61
|
| Rate for Payer: Amerigroup Medicaid |
$0.54
|
| Rate for Payer: Amerigroup Medicare |
$0.54
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.53
|
| Rate for Payer: Medical Associates Commercial |
$0.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.54
|
| Rate for Payer: Midlands Choice Commercial |
$0.75
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$0.96
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.63
|
|
|
hydrochlorothiazide 25 mg Tab
|
Facility
IP
|
$1.07
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of IA Commercial |
$0.96
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.96
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.80
|
| Rate for Payer: Medical Associates Commercial |
$0.80
|
| Rate for Payer: Midlands Choice Commercial |
$0.75
|
| Rate for Payer: United Healthcare Commercial |
$0.96
|
|
|
hydrochlorothiazide-triamterene 25 MG-37.5 MG
|
Facility
OP
|
$1.44
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of IA Commercial |
$1.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.30
|
| Rate for Payer: Aetna of IA Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicaid |
$0.73
|
| Rate for Payer: Amerigroup Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.72
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.72
|
| Rate for Payer: Medical Associates Commercial |
$1.08
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.72
|
| Rate for Payer: Midlands Choice Commercial |
$1.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.85
|
|
