|
silver sulfADIAZINE Top 1% Crm 50 gm
|
Facility
OP
|
$35.64
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701410
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.81 |
| Max. Negotiated Rate |
$32.08 |
| Rate for Payer: Aetna of IA Commercial |
$32.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.08
|
| Rate for Payer: Aetna of IA Medicare |
$20.31
|
| Rate for Payer: Amerigroup Medicaid |
$17.99
|
| Rate for Payer: Amerigroup Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$28.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.73
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$17.82
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$17.81
|
| Rate for Payer: Medical Associates Commercial |
$26.73
|
| Rate for Payer: Medical Associates Managed Medicare |
$17.82
|
| Rate for Payer: Midlands Choice Commercial |
$24.95
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$26.73
|
| Rate for Payer: United Healthcare Commercial |
$32.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$21.03
|
|
|
silver sulfADIAZINE Top 1% Crm 50 gm
|
Facility
IP
|
$35.64
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701410
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.95 |
| Max. Negotiated Rate |
$32.08 |
| Rate for Payer: Aetna of IA Commercial |
$32.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.08
|
| Rate for Payer: Cash Price |
$28.51
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$26.73
|
| Rate for Payer: Medical Associates Commercial |
$26.73
|
| Rate for Payer: Midlands Choice Commercial |
$24.95
|
| Rate for Payer: United Healthcare Commercial |
$32.08
|
|
|
simethicone 125 mg Chew Tab
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of IA Commercial |
$1.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.04
|
| Rate for Payer: Aetna of IA Medicare |
$0.66
|
| Rate for Payer: Amerigroup Medicaid |
$0.59
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.87
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.58
|
| Rate for Payer: Medical Associates Commercial |
$0.87
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.87
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.68
|
|
|
simethicone 125 mg Chew Tab
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700579
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of IA Commercial |
$1.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.04
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.87
|
| Rate for Payer: Medical Associates Commercial |
$0.87
|
| Rate for Payer: Midlands Choice Commercial |
$0.81
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
|
|
simethicone 40 mg/0.6 mL Liq 30ml
|
Facility
IP
|
$16.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$14.51 |
| Rate for Payer: Aetna of IA Commercial |
$14.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.51
|
| Rate for Payer: Cash Price |
$12.90
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.09
|
| Rate for Payer: Medical Associates Commercial |
$12.09
|
| Rate for Payer: Midlands Choice Commercial |
$11.28
|
| Rate for Payer: United Healthcare Commercial |
$14.51
|
|
|
simethicone 40 mg/0.6 mL Liq 30ml
|
Facility
OP
|
$16.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$14.51 |
| Rate for Payer: Aetna of IA Commercial |
$14.51
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$14.51
|
| Rate for Payer: Aetna of IA Medicare |
$9.19
|
| Rate for Payer: Amerigroup Medicaid |
$8.14
|
| Rate for Payer: Amerigroup Medicare |
$8.14
|
| Rate for Payer: Cash Price |
$12.90
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$12.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.06
|
| Rate for Payer: Medical Associates Commercial |
$12.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.06
|
| Rate for Payer: Midlands Choice Commercial |
$11.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.09
|
| Rate for Payer: United Healthcare Commercial |
$14.51
|
| Rate for Payer: United Healthcare Managed Medicare |
$9.51
|
|
|
simethicone 80 mg Chew Tab
|
Facility
IP
|
$1.06
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of IA Commercial |
$0.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.95
|
| 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 |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
|
|
simethicone 80 mg Chew Tab
|
Facility
OP
|
$1.06
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of IA Commercial |
$0.95
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$0.95
|
| Rate for Payer: Aetna of IA Medicare |
$0.60
|
| Rate for Payer: Amerigroup Medicaid |
$0.53
|
| 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 |
$0.53
|
| 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 |
$0.53
|
| Rate for Payer: Midlands Choice Commercial |
$0.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.63
|
|
|
SIMPLE CPAP SUBSQ
|
Facility
IP
|
$521.00
|
|
|
Service Code
|
CPT 94660
|
| Hospital Charge Code |
5800782
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$364.70 |
| Max. Negotiated Rate |
$468.90 |
| Rate for Payer: Aetna of IA Commercial |
$468.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$468.90
|
| Rate for Payer: Cash Price |
$416.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$390.75
|
| Rate for Payer: Medical Associates Commercial |
$390.75
|
| Rate for Payer: Midlands Choice Commercial |
$364.70
|
| Rate for Payer: United Healthcare Commercial |
$468.90
|
|
|
SIMPLE CPAP SUBSQ
|
Facility
OP
|
$521.00
|
|
|
Service Code
|
CPT 94660
|
| Hospital Charge Code |
5800782
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$260.40 |
| Max. Negotiated Rate |
$856.59 |
| Rate for Payer: Midlands Choice Commercial |
$364.70
|
| Rate for Payer: Aetna of IA Commercial |
$468.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$468.90
|
| Rate for Payer: Aetna of IA Medicare |
$296.97
|
| Rate for Payer: Amerigroup Medicaid |
$262.95
|
| Rate for Payer: Amerigroup Medicare |
$263.10
|
| Rate for Payer: Cash Price |
$416.80
|
| Rate for Payer: Cash Price |
$416.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$390.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$260.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$260.40
|
| Rate for Payer: Medical Associates Commercial |
$390.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$260.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$264.41
|
| Rate for Payer: Partners Health Alliance Commercial |
$390.75
|
| Rate for Payer: United Healthcare Commercial |
$468.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$307.39
|
| Rate for Payer: Wellmark IA HMO |
$778.72
|
| Rate for Payer: Wellmark IA PPO |
$856.59
|
|
|
Simple Pneumonia and Pleurisy With CC
|
Facility
IP
|
$6,955.63
|
|
|
Service Code
|
MS-DRG 194
|
| Hospital Charge Code |
65
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$6,955.63 |
| Rate for Payer: Amerigroup Medicaid |
$6,922.03
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,854.83
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,955.63
|
|
|
Simple Pneumonia and Pleurisy With MCC
|
Facility
IP
|
$10,653.43
|
|
|
Service Code
|
MS-DRG 193
|
| Hospital Charge Code |
64
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$10,653.43 |
| Rate for Payer: Amerigroup Medicaid |
$10,601.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10,499.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,653.43
|
|
|
Simple Pneumonia and Pleurisy Without CC/MCC
|
Facility
IP
|
$4,821.80
|
|
|
Service Code
|
MS-DRG 195
|
| Hospital Charge Code |
66
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$4,821.80 |
| Rate for Payer: Amerigroup Medicaid |
$4,798.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,751.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,821.80
|
|
|
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less
|
Facility
OP
|
$598.11
|
|
|
Service Code
|
CPT 12011
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$543.74 |
| Max. Negotiated Rate |
$598.11 |
| Rate for Payer: Wellmark IA HMO |
$543.74
|
| Rate for Payer: Wellmark IA PPO |
$598.11
|
|
|
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm
|
Facility
OP
|
$598.11
|
|
|
Service Code
|
CPT 12013
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$543.74 |
| Max. Negotiated Rate |
$598.11 |
| Rate for Payer: Wellmark IA HMO |
$543.74
|
| Rate for Payer: Wellmark IA PPO |
$598.11
|
|
|
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm
|
Facility
OP
|
$598.11
|
|
|
Service Code
|
CPT 12015
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$543.74 |
| Max. Negotiated Rate |
$598.11 |
| Rate for Payer: Wellmark IA HMO |
$543.74
|
| Rate for Payer: Wellmark IA PPO |
$598.11
|
|
|
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
|
Facility
OP
|
$598.11
|
|
|
Service Code
|
CPT 12001
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$543.74 |
| Max. Negotiated Rate |
$598.11 |
| Rate for Payer: Wellmark IA HMO |
$543.74
|
| Rate for Payer: Wellmark IA PPO |
$598.11
|
|
|
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
|
Facility
OP
|
$598.11
|
|
|
Service Code
|
CPT 12002
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$543.74 |
| Max. Negotiated Rate |
$598.11 |
| Rate for Payer: Wellmark IA HMO |
$543.74
|
| Rate for Payer: Wellmark IA PPO |
$598.11
|
|
|
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm
|
Facility
OP
|
$598.11
|
|
|
Service Code
|
CPT 12004
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$543.74 |
| Max. Negotiated Rate |
$598.11 |
| Rate for Payer: Wellmark IA HMO |
$543.74
|
| Rate for Payer: Wellmark IA PPO |
$598.11
|
|
|
SIMPLE SPIROMETRY
|
Facility
IP
|
$260.00
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
7826320
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna of IA Commercial |
$234.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$234.00
|
| Rate for Payer: Cash Price |
$208.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$195.00
|
| Rate for Payer: Medical Associates Commercial |
$195.00
|
| Rate for Payer: Midlands Choice Commercial |
$182.00
|
| Rate for Payer: United Healthcare Commercial |
$234.00
|
|
|
SIMPLE SPIROMETRY
|
Facility
OP
|
$260.00
|
|
|
Service Code
|
CPT 94010
|
| Hospital Charge Code |
7826320
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$129.95 |
| Max. Negotiated Rate |
$282.35 |
| Rate for Payer: Aetna of IA Commercial |
$234.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$234.00
|
| Rate for Payer: Aetna of IA Medicare |
$148.20
|
| Rate for Payer: Amerigroup Medicaid |
$131.22
|
| Rate for Payer: Amerigroup Medicare |
$131.30
|
| Rate for Payer: Cash Price |
$208.00
|
| Rate for Payer: Cash Price |
$208.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$195.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$130.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$129.95
|
| Rate for Payer: Medical Associates Commercial |
$195.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$130.00
|
| Rate for Payer: Midlands Choice Commercial |
$182.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$131.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$195.00
|
| Rate for Payer: United Healthcare Commercial |
$234.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$153.40
|
| Rate for Payer: Wellmark IA HMO |
$256.68
|
| Rate for Payer: Wellmark IA PPO |
$282.35
|
|
|
Simultaneous Pancreas and Kidney Transplant
|
Facility
IP
|
$135,189.52
|
|
|
Service Code
|
MS-DRG 008
|
| Hospital Charge Code |
699
|
| Min. Negotiated Rate |
$133,230.25 |
| Max. Negotiated Rate |
$135,189.52 |
| Rate for Payer: Amerigroup Medicaid |
$134,536.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$133,230.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$135,189.52
|
|
|
Simultaneous Pancreas and Kidney Transplant With Hemodialysis
|
Facility
IP
|
$65,585.92
|
|
|
Service Code
|
MS-DRG 019
|
| Hospital Charge Code |
708
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$65,585.92 |
| Rate for Payer: Amerigroup Medicaid |
$65,269.08
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$64,635.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$65,585.92
|
|
|
simvastatin 20 mg Tab
|
Facility
IP
|
$1.47
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43799247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna of IA Commercial |
$1.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.32
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.10
|
| Rate for Payer: Medical Associates Commercial |
$1.10
|
| Rate for Payer: Midlands Choice Commercial |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$1.32
|
|
|
simvastatin 20 mg Tab
|
Facility
OP
|
$1.47
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43799247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Aetna of IA Commercial |
$1.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.32
|
| Rate for Payer: Aetna of IA Medicare |
$0.84
|
| Rate for Payer: Amerigroup Medicaid |
$0.74
|
| Rate for Payer: Amerigroup Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.73
|
| Rate for Payer: Medical Associates Commercial |
$1.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.74
|
| Rate for Payer: Midlands Choice Commercial |
$1.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.87
|
|
