|
Sodium Chloride 0.9% IV Sol 250 mL
|
Facility
OP
|
$65.26
|
|
|
Service Code
|
CPT J7050
|
| Hospital Charge Code |
43700045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.62 |
| Max. Negotiated Rate |
$58.73 |
| Rate for Payer: Aetna of IA Commercial |
$58.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.73
|
| Rate for Payer: Aetna of IA Medicare |
$37.20
|
| Rate for Payer: Amerigroup Medicaid |
$32.94
|
| Rate for Payer: Amerigroup Medicare |
$32.96
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$32.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.62
|
| Rate for Payer: Medical Associates Commercial |
$48.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.63
|
| Rate for Payer: Midlands Choice Commercial |
$45.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$48.94
|
| Rate for Payer: United Healthcare Commercial |
$58.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.50
|
|
|
Sodium Chloride 0.9% IV Sol 250 mL
|
Facility
IP
|
$65.26
|
|
|
Service Code
|
CPT J7050
|
| Hospital Charge Code |
43700045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.68 |
| Max. Negotiated Rate |
$58.73 |
| Rate for Payer: Aetna of IA Commercial |
$58.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$58.73
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$48.94
|
| Rate for Payer: Medical Associates Commercial |
$48.94
|
| Rate for Payer: Midlands Choice Commercial |
$45.68
|
| Rate for Payer: United Healthcare Commercial |
$58.73
|
|
|
Sodium Chloride 0.9% IV Sol 50 mL
|
Facility
OP
|
$66.80
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.39 |
| Max. Negotiated Rate |
$60.12 |
| Rate for Payer: Aetna of IA Commercial |
$60.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.12
|
| Rate for Payer: Aetna of IA Medicare |
$38.08
|
| Rate for Payer: Amerigroup Medicaid |
$33.71
|
| Rate for Payer: Amerigroup Medicare |
$33.73
|
| Rate for Payer: Cash Price |
$53.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$33.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.39
|
| Rate for Payer: Medical Associates Commercial |
$50.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.40
|
| Rate for Payer: Midlands Choice Commercial |
$46.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$50.10
|
| Rate for Payer: United Healthcare Commercial |
$60.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.41
|
|
|
Sodium Chloride 0.9% IV Sol 50 mL
|
Facility
IP
|
$66.80
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$60.12 |
| Rate for Payer: Aetna of IA Commercial |
$60.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.12
|
| Rate for Payer: Cash Price |
$53.44
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.10
|
| Rate for Payer: Medical Associates Commercial |
$50.10
|
| Rate for Payer: Midlands Choice Commercial |
$46.76
|
| Rate for Payer: United Healthcare Commercial |
$60.12
|
|
|
sodium chloride 1 g Tab
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
CPT A4216
|
| Hospital Charge Code |
43700324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Aetna of IA Medicare |
$0.72
|
| Rate for Payer: Amerigroup Medicaid |
$0.64
|
| Rate for Payer: Amerigroup Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.63
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.63
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
|
sodium chloride 1 g Tab
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
CPT A4216
|
| Hospital Charge Code |
43700324
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
|
|
sodium chloride 7% UD neb sol 4ml SDV
|
Facility
IP
|
$6.33
|
|
|
Service Code
|
CPT J7131
|
| Hospital Charge Code |
43788187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Aetna of IA Commercial |
$5.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.70
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.75
|
| Rate for Payer: Medical Associates Commercial |
$4.75
|
| Rate for Payer: Midlands Choice Commercial |
$4.43
|
| Rate for Payer: United Healthcare Commercial |
$5.70
|
|
|
sodium chloride 7% UD neb sol 4ml SDV
|
Facility
OP
|
$6.33
|
|
|
Service Code
|
CPT J7131
|
| Hospital Charge Code |
43788187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Aetna of IA Commercial |
$5.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.70
|
| Rate for Payer: Aetna of IA Medicare |
$3.61
|
| Rate for Payer: Amerigroup Medicaid |
$3.19
|
| Rate for Payer: Amerigroup Medicare |
$3.20
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$3.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3.16
|
| Rate for Payer: Medical Associates Commercial |
$4.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$3.16
|
| Rate for Payer: Midlands Choice Commercial |
$4.43
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3.21
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.75
|
| Rate for Payer: United Healthcare Commercial |
$5.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.73
|
|
|
Sodium Chloride HYPERTONIC 3% IV Sol 500 mL
|
Facility
OP
|
$67.18
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$60.46 |
| Rate for Payer: Aetna of IA Commercial |
$60.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.46
|
| Rate for Payer: Aetna of IA Medicare |
$38.29
|
| Rate for Payer: Amerigroup Medicaid |
$33.91
|
| Rate for Payer: Amerigroup Medicare |
$33.93
|
| Rate for Payer: Cash Price |
$53.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$33.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.58
|
| Rate for Payer: Medical Associates Commercial |
$50.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.59
|
| Rate for Payer: Midlands Choice Commercial |
$47.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$34.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$50.38
|
| Rate for Payer: United Healthcare Commercial |
$60.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.64
|
|
|
Sodium Chloride HYPERTONIC 3% IV Sol 500 mL
|
Facility
IP
|
$67.18
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.03 |
| Max. Negotiated Rate |
$60.46 |
| Rate for Payer: Aetna of IA Commercial |
$60.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.46
|
| Rate for Payer: Cash Price |
$53.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.38
|
| Rate for Payer: Medical Associates Commercial |
$50.38
|
| Rate for Payer: Midlands Choice Commercial |
$47.03
|
| Rate for Payer: United Healthcare Commercial |
$60.46
|
|
|
sodium chloride, hypertonic, Ophth 5% Sol
|
Facility
IP
|
$49.80
|
|
|
Service Code
|
CPT J2916
|
| Hospital Charge Code |
43700525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.86 |
| Max. Negotiated Rate |
$44.82 |
| Rate for Payer: Aetna of IA Commercial |
$44.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.82
|
| Rate for Payer: Cash Price |
$39.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.35
|
| Rate for Payer: Medical Associates Commercial |
$37.35
|
| Rate for Payer: Midlands Choice Commercial |
$34.86
|
| Rate for Payer: United Healthcare Commercial |
$44.82
|
|
|
sodium chloride, hypertonic, Ophth 5% Sol
|
Facility
OP
|
$49.80
|
|
|
Service Code
|
CPT J2916
|
| Hospital Charge Code |
43700525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$44.82 |
| Rate for Payer: Aetna of IA Commercial |
$44.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.82
|
| Rate for Payer: Aetna of IA Medicare |
$28.39
|
| Rate for Payer: Amerigroup Medicaid |
$25.13
|
| Rate for Payer: Amerigroup Medicare |
$25.15
|
| Rate for Payer: Cash Price |
$39.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.89
|
| Rate for Payer: Medical Associates Commercial |
$37.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.90
|
| Rate for Payer: Midlands Choice Commercial |
$34.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$37.35
|
| Rate for Payer: United Healthcare Commercial |
$44.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$29.38
|
|
|
sodium chloride nasal 0.65% Gel
|
Facility
IP
|
$26.68
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.68 |
| Max. Negotiated Rate |
$24.01 |
| Rate for Payer: Aetna of IA Commercial |
$24.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.01
|
| Rate for Payer: Cash Price |
$21.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.01
|
| Rate for Payer: Medical Associates Commercial |
$20.01
|
| Rate for Payer: Midlands Choice Commercial |
$18.68
|
| Rate for Payer: United Healthcare Commercial |
$24.01
|
|
|
sodium chloride nasal 0.65% Gel
|
Facility
OP
|
$26.68
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$24.01 |
| Rate for Payer: Aetna of IA Commercial |
$24.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.01
|
| Rate for Payer: Aetna of IA Medicare |
$15.21
|
| Rate for Payer: Amerigroup Medicaid |
$13.47
|
| Rate for Payer: Amerigroup Medicare |
$13.47
|
| Rate for Payer: Cash Price |
$21.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.33
|
| Rate for Payer: Medical Associates Commercial |
$20.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.34
|
| Rate for Payer: Midlands Choice Commercial |
$18.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.01
|
| Rate for Payer: United Healthcare Commercial |
$24.01
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.74
|
|
|
sodium chloride Nasal 0.65% Spry
|
Facility
OP
|
$17.36
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43760188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Aetna of IA Commercial |
$15.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.62
|
| Rate for Payer: Aetna of IA Medicare |
$9.90
|
| Rate for Payer: Amerigroup Medicaid |
$8.76
|
| Rate for Payer: Amerigroup Medicare |
$8.77
|
| Rate for Payer: Cash Price |
$13.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$8.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.68
|
| Rate for Payer: Medical Associates Commercial |
$13.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.68
|
| Rate for Payer: Midlands Choice Commercial |
$12.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.02
|
| Rate for Payer: United Healthcare Commercial |
$15.62
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.24
|
|
|
sodium chloride Nasal 0.65% Spry
|
Facility
IP
|
$17.36
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43760188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Aetna of IA Commercial |
$15.62
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$15.62
|
| Rate for Payer: Cash Price |
$13.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.02
|
| Rate for Payer: Medical Associates Commercial |
$13.02
|
| Rate for Payer: Midlands Choice Commercial |
$12.15
|
| Rate for Payer: United Healthcare Commercial |
$15.62
|
|
|
sodium ferric gluconate complex 12.5 mg/mL 5ml SDV
|
Facility
OP
|
$52.94
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701588
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$47.65 |
| Rate for Payer: Aetna of IA Commercial |
$47.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.65
|
| Rate for Payer: Aetna of IA Medicare |
$30.18
|
| Rate for Payer: Amerigroup Medicaid |
$26.72
|
| Rate for Payer: Amerigroup Medicare |
$26.73
|
| Rate for Payer: Cash Price |
$42.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.47
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.46
|
| Rate for Payer: Medical Associates Commercial |
$39.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.47
|
| Rate for Payer: Midlands Choice Commercial |
$37.06
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.70
|
| Rate for Payer: United Healthcare Commercial |
$47.65
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.23
|
|
|
sodium ferric gluconate complex 12.5 mg/mL 5ml SDV
|
Facility
IP
|
$52.94
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701588
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.06 |
| Max. Negotiated Rate |
$47.65 |
| Rate for Payer: Aetna of IA Commercial |
$47.65
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.65
|
| Rate for Payer: Cash Price |
$42.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.70
|
| Rate for Payer: Medical Associates Commercial |
$39.70
|
| Rate for Payer: Midlands Choice Commercial |
$37.06
|
| Rate for Payer: United Healthcare Commercial |
$47.65
|
|
|
Sodium Nitroprusside 25 mg/mL 2ml SDV
|
Facility
OP
|
$67.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.79 |
| Max. Negotiated Rate |
$60.84 |
| Rate for Payer: Aetna of IA Commercial |
$60.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.84
|
| Rate for Payer: Aetna of IA Medicare |
$38.53
|
| Rate for Payer: Amerigroup Medicaid |
$34.12
|
| Rate for Payer: Amerigroup Medicare |
$34.14
|
| Rate for Payer: Cash Price |
$54.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$33.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.79
|
| Rate for Payer: Medical Associates Commercial |
$50.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.80
|
| Rate for Payer: Midlands Choice Commercial |
$47.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$34.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$50.70
|
| Rate for Payer: United Healthcare Commercial |
$60.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$39.88
|
|
|
Sodium Nitroprusside 25 mg/mL 2ml SDV
|
Facility
IP
|
$67.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.32 |
| Max. Negotiated Rate |
$60.84 |
| Rate for Payer: Aetna of IA Commercial |
$60.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$60.84
|
| Rate for Payer: Cash Price |
$54.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$50.70
|
| Rate for Payer: Medical Associates Commercial |
$50.70
|
| Rate for Payer: Midlands Choice Commercial |
$47.32
|
| Rate for Payer: United Healthcare Commercial |
$60.84
|
|
|
sodium polystyrene sulfonate 15 g/60 mL Oral Susp
|
Facility
IP
|
$75.74
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43727530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.02 |
| Max. Negotiated Rate |
$68.17 |
| Rate for Payer: Aetna of IA Commercial |
$68.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.17
|
| Rate for Payer: Cash Price |
$60.59
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$56.80
|
| Rate for Payer: Medical Associates Commercial |
$56.80
|
| Rate for Payer: Midlands Choice Commercial |
$53.02
|
| Rate for Payer: United Healthcare Commercial |
$68.17
|
|
|
sodium polystyrene sulfonate 15 g/60 mL Oral Susp
|
Facility
OP
|
$75.74
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43727530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.85 |
| Max. Negotiated Rate |
$68.17 |
| Rate for Payer: Aetna of IA Commercial |
$68.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$68.17
|
| Rate for Payer: Aetna of IA Medicare |
$43.17
|
| Rate for Payer: Amerigroup Medicaid |
$38.23
|
| Rate for Payer: Amerigroup Medicare |
$38.25
|
| Rate for Payer: Cash Price |
$60.59
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$56.80
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$37.87
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37.85
|
| Rate for Payer: Medical Associates Commercial |
$56.80
|
| Rate for Payer: Medical Associates Managed Medicare |
$37.87
|
| Rate for Payer: Midlands Choice Commercial |
$53.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$38.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$56.80
|
| Rate for Payer: United Healthcare Commercial |
$68.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$44.69
|
|
|
Soft Tissue Procedures With CC
|
Facility
IP
|
$12,716.40
|
|
|
Service Code
|
MS-DRG 501
|
| Hospital Charge Code |
318
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$12,716.40 |
| Rate for Payer: Amerigroup Medicaid |
$12,654.97
|
| 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 |
$12,532.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12,716.40
|
|
|
Soft Tissue Procedures With MCC
|
Facility
IP
|
$19,360.03
|
|
|
Service Code
|
MS-DRG 500
|
| Hospital Charge Code |
317
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$19,360.03 |
| Rate for Payer: Amerigroup Medicaid |
$19,266.50
|
| 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 |
$19,079.45
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19,360.03
|
|
|
Soft Tissue Procedures Without CC/MCC
|
Facility
IP
|
$10,835.52
|
|
|
Service Code
|
MS-DRG 502
|
| Hospital Charge Code |
319
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$10,835.52 |
| Rate for Payer: Amerigroup Medicaid |
$10,783.17
|
| 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 |
$10,678.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,835.52
|
|
