|
STRESS TEST
|
Facility
|
IP
|
$738.00
|
|
|
Service Code
|
CPT 93017
|
| Hospital Charge Code |
8012934
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$516.60 |
| Max. Negotiated Rate |
$664.20 |
| Rate for Payer: Aetna of IA Commercial |
$664.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$664.20
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$553.50
|
| Rate for Payer: Medical Associates Commercial |
$553.50
|
| Rate for Payer: Midlands Choice Commercial |
$516.60
|
| Rate for Payer: United Healthcare Commercial |
$664.20
|
|
|
SUBCUTANEOUS/MUSCLE BONE EA ADD 20 SQ CM
|
Facility
|
OP
|
$671.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
8013697
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$301.95 |
| Max. Negotiated Rate |
$603.90 |
| Rate for Payer: Aetna of IA Commercial |
$603.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$603.90
|
| Rate for Payer: Aetna of IA Medicare |
$382.47
|
| Rate for Payer: Amerigroup Medicaid |
$387.03
|
| Rate for Payer: Amerigroup Medicare |
$304.97
|
| Rate for Payer: Cash Price |
$536.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$503.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$301.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$383.28
|
| Rate for Payer: Medical Associates Commercial |
$503.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$301.95
|
| Rate for Payer: Midlands Choice Commercial |
$469.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$388.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$347.24
|
| Rate for Payer: United Healthcare Commercial |
$603.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$395.89
|
|
|
SUBCUTANEOUS/MUSCLE BONE EA ADD 20 SQ CM
|
Facility
|
IP
|
$671.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
8013697
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$469.70 |
| Max. Negotiated Rate |
$603.90 |
| Rate for Payer: Aetna of IA Commercial |
$603.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$603.90
|
| Rate for Payer: Cash Price |
$536.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$503.25
|
| Rate for Payer: Medical Associates Commercial |
$503.25
|
| Rate for Payer: Midlands Choice Commercial |
$469.70
|
| Rate for Payer: United Healthcare Commercial |
$603.90
|
|
|
succinylcholine 20 mg/mL 10ml MDV Inj Sol [VDMC]
|
Facility
|
IP
|
$29.42
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
10422656
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.59 |
| Max. Negotiated Rate |
$26.48 |
| Rate for Payer: Aetna of IA Commercial |
$26.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.48
|
| Rate for Payer: Cash Price |
$23.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.06
|
| Rate for Payer: Medical Associates Commercial |
$22.06
|
| Rate for Payer: Midlands Choice Commercial |
$20.59
|
| Rate for Payer: United Healthcare Commercial |
$26.48
|
|
|
succinylcholine 20 mg/mL 10ml MDV Inj Sol [VDMC]
|
Facility
|
OP
|
$29.42
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
10422656
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.24 |
| Max. Negotiated Rate |
$26.48 |
| Rate for Payer: Aetna of IA Commercial |
$26.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.48
|
| Rate for Payer: Aetna of IA Medicare |
$16.77
|
| Rate for Payer: Amerigroup Medicaid |
$16.97
|
| Rate for Payer: Amerigroup Medicare |
$13.37
|
| Rate for Payer: Cash Price |
$23.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.80
|
| Rate for Payer: Medical Associates Commercial |
$22.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.24
|
| Rate for Payer: Midlands Choice Commercial |
$20.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.22
|
| Rate for Payer: United Healthcare Commercial |
$26.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.36
|
|
|
sucralfate 1 g/10 mL Oral Susp [VDMC]
|
Facility
|
OP
|
$29.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10430513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna of IA Commercial |
$26.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.68
|
| Rate for Payer: Aetna of IA Medicare |
$16.90
|
| Rate for Payer: Amerigroup Medicaid |
$17.10
|
| Rate for Payer: Amerigroup Medicare |
$13.47
|
| Rate for Payer: Cash Price |
$23.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.23
|
| 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 |
$16.93
|
| Rate for Payer: Medical Associates Commercial |
$22.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.34
|
| Rate for Payer: Midlands Choice Commercial |
$20.75
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$15.34
|
| Rate for Payer: United Healthcare Commercial |
$26.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.49
|
|
|
sucralfate 1 g/10 mL Oral Susp [VDMC]
|
Facility
|
IP
|
$29.64
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10430513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$26.68 |
| Rate for Payer: Aetna of IA Commercial |
$26.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.68
|
| Rate for Payer: Cash Price |
$23.72
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.23
|
| Rate for Payer: Medical Associates Commercial |
$22.23
|
| Rate for Payer: Midlands Choice Commercial |
$20.75
|
| Rate for Payer: United Healthcare Commercial |
$26.68
|
|
|
sucralfate 1 g Tab [VDMC]
|
Facility
|
IP
|
$2.23
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422727
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna of IA Commercial |
$2.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.01
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.68
|
| Rate for Payer: Medical Associates Commercial |
$1.68
|
| Rate for Payer: Midlands Choice Commercial |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
|
|
sucralfate 1 g Tab [VDMC]
|
Facility
|
OP
|
$2.23
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422727
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna of IA Commercial |
$2.01
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.01
|
| Rate for Payer: Aetna of IA Medicare |
$1.27
|
| Rate for Payer: Amerigroup Medicaid |
$1.29
|
| Rate for Payer: Amerigroup Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.28
|
| Rate for Payer: Medical Associates Commercial |
$1.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.01
|
| Rate for Payer: Midlands Choice Commercial |
$1.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.32
|
|
|
sugammadex 100 mg/mL 2 ml SDV [VDMC]
|
Facility
|
IP
|
$537.32
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15247256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$376.12 |
| Max. Negotiated Rate |
$483.58 |
| Rate for Payer: Aetna of IA Commercial |
$483.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$483.58
|
| Rate for Payer: Cash Price |
$429.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$402.99
|
| Rate for Payer: Medical Associates Commercial |
$402.99
|
| Rate for Payer: Midlands Choice Commercial |
$376.12
|
| Rate for Payer: United Healthcare Commercial |
$483.58
|
|
|
sugammadex 100 mg/mL 2 ml SDV [VDMC]
|
Facility
|
OP
|
$537.32
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15247256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$241.79 |
| Max. Negotiated Rate |
$483.58 |
| Rate for Payer: Aetna of IA Commercial |
$483.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$483.58
|
| Rate for Payer: Aetna of IA Medicare |
$306.27
|
| Rate for Payer: Amerigroup Medicaid |
$309.92
|
| Rate for Payer: Amerigroup Medicare |
$244.21
|
| Rate for Payer: Cash Price |
$429.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$402.99
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$241.79
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$306.91
|
| Rate for Payer: Medical Associates Commercial |
$402.99
|
| Rate for Payer: Medical Associates Managed Medicare |
$241.79
|
| Rate for Payer: Midlands Choice Commercial |
$376.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$311.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$278.06
|
| Rate for Payer: United Healthcare Commercial |
$483.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$317.02
|
|
|
Sulfacetamide Sodium Opht10% Sol 15 ml [VDMC]
|
Facility
|
OP
|
$145.60
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10439128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$131.04 |
| Rate for Payer: Aetna of IA Commercial |
$131.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.04
|
| Rate for Payer: Aetna of IA Medicare |
$82.99
|
| Rate for Payer: Amerigroup Medicaid |
$83.98
|
| Rate for Payer: Amerigroup Medicare |
$66.18
|
| Rate for Payer: Cash Price |
$116.48
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$65.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$83.17
|
| Rate for Payer: Medical Associates Commercial |
$109.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.52
|
| Rate for Payer: Midlands Choice Commercial |
$101.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$84.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$75.35
|
| Rate for Payer: United Healthcare Commercial |
$131.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$85.90
|
|
|
Sulfacetamide Sodium Opht10% Sol 15 ml [VDMC]
|
Facility
|
IP
|
$145.60
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10439128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$131.04 |
| Rate for Payer: Aetna of IA Commercial |
$131.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.04
|
| Rate for Payer: Cash Price |
$116.48
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.20
|
| Rate for Payer: Medical Associates Commercial |
$109.20
|
| Rate for Payer: Midlands Choice Commercial |
$101.92
|
| Rate for Payer: United Healthcare Commercial |
$131.04
|
|
|
sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Sus 20 mL UD[VDMC]
|
Facility
|
OP
|
$9.70
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11681944
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Aetna of IA Commercial |
$8.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.73
|
| Rate for Payer: Aetna of IA Medicare |
$5.53
|
| Rate for Payer: Amerigroup Medicaid |
$5.60
|
| Rate for Payer: Amerigroup Medicare |
$4.41
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.37
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5.54
|
| Rate for Payer: Medical Associates Commercial |
$7.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.37
|
| Rate for Payer: Midlands Choice Commercial |
$6.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$5.02
|
| Rate for Payer: United Healthcare Commercial |
$8.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.72
|
|
|
sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Sus 20 mL UD[VDMC]
|
Facility
|
IP
|
$9.70
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11681944
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Aetna of IA Commercial |
$8.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.73
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.28
|
| Rate for Payer: Medical Associates Commercial |
$7.28
|
| Rate for Payer: Midlands Choice Commercial |
$6.79
|
| Rate for Payer: United Healthcare Commercial |
$8.73
|
|
|
sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [VDMC]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of IA Commercial |
$1.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.33
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.11
|
| Rate for Payer: Medical Associates Commercial |
$1.11
|
| Rate for Payer: Midlands Choice Commercial |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
|
|
sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [VDMC]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of IA Commercial |
$1.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.33
|
| Rate for Payer: Aetna of IA Medicare |
$0.84
|
| Rate for Payer: Amerigroup Medicaid |
$0.85
|
| Rate for Payer: Amerigroup Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.11
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.84
|
| Rate for Payer: Medical Associates Commercial |
$1.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.66
|
| Rate for Payer: Midlands Choice Commercial |
$1.03
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.76
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.87
|
|
|
sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol [VDMC]
|
Facility
|
OP
|
$47.95
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11224670
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$43.15 |
| Rate for Payer: Aetna of IA Commercial |
$43.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.15
|
| Rate for Payer: Aetna of IA Medicare |
$27.33
|
| Rate for Payer: Amerigroup Medicaid |
$27.66
|
| Rate for Payer: Amerigroup Medicare |
$21.79
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$35.96
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27.39
|
| Rate for Payer: Medical Associates Commercial |
$35.96
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.58
|
| Rate for Payer: Midlands Choice Commercial |
$33.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.81
|
| Rate for Payer: United Healthcare Commercial |
$43.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.29
|
|
|
sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol [VDMC]
|
Facility
|
IP
|
$47.95
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11224670
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.56 |
| Max. Negotiated Rate |
$43.15 |
| Rate for Payer: Aetna of IA Commercial |
$43.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.15
|
| Rate for Payer: Cash Price |
$38.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$35.96
|
| Rate for Payer: Medical Associates Commercial |
$35.96
|
| Rate for Payer: Midlands Choice Commercial |
$33.56
|
| Rate for Payer: United Healthcare Commercial |
$43.15
|
|
|
sulfaSALAzine 500 mg Tab [VDMC]
|
Facility
|
IP
|
$1.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna of IA Commercial |
$1.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.54
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.29
|
| Rate for Payer: Medical Associates Commercial |
$1.29
|
| Rate for Payer: Midlands Choice Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
|
|
sulfaSALAzine 500 mg Tab [VDMC]
|
Facility
|
OP
|
$1.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Aetna of IA Commercial |
$1.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.54
|
| Rate for Payer: Aetna of IA Medicare |
$0.98
|
| Rate for Payer: Amerigroup Medicaid |
$0.99
|
| Rate for Payer: Amerigroup Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.29
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.98
|
| Rate for Payer: Medical Associates Commercial |
$1.29
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.77
|
| Rate for Payer: Midlands Choice Commercial |
$1.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.89
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.01
|
|
|
SUMAtriptan 100 mg Tab [VDMC]
|
Facility
|
OP
|
$2.99
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Aetna of IA Commercial |
$2.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.69
|
| Rate for Payer: Aetna of IA Medicare |
$1.70
|
| Rate for Payer: Amerigroup Medicaid |
$1.72
|
| Rate for Payer: Amerigroup Medicare |
$1.36
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.71
|
| Rate for Payer: Medical Associates Commercial |
$2.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.34
|
| Rate for Payer: Midlands Choice Commercial |
$2.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.76
|
|
|
SUMAtriptan 100 mg Tab [VDMC]
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Aetna of IA Commercial |
$2.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.69
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.24
|
| Rate for Payer: Medical Associates Commercial |
$2.24
|
| Rate for Payer: Midlands Choice Commercial |
$2.09
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
|
|
SUMAtriptan 6 mg/0.5 mL SubQ SDV [VDMC]
|
Facility
|
OP
|
$33.70
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
10423141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.17 |
| Max. Negotiated Rate |
$30.33 |
| Rate for Payer: Aetna of IA Commercial |
$30.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.33
|
| Rate for Payer: Aetna of IA Medicare |
$19.21
|
| Rate for Payer: Amerigroup Medicaid |
$19.44
|
| Rate for Payer: Amerigroup Medicare |
$15.32
|
| Rate for Payer: Cash Price |
$26.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.17
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.25
|
| Rate for Payer: Medical Associates Commercial |
$25.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.17
|
| Rate for Payer: Midlands Choice Commercial |
$23.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.44
|
| Rate for Payer: United Healthcare Commercial |
$30.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$19.89
|
|
|
SUMAtriptan 6 mg/0.5 mL SubQ SDV [VDMC]
|
Facility
|
IP
|
$33.70
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
10423141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.59 |
| Max. Negotiated Rate |
$30.33 |
| Rate for Payer: Aetna of IA Commercial |
$30.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$30.33
|
| Rate for Payer: Cash Price |
$26.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$25.28
|
| Rate for Payer: Medical Associates Commercial |
$25.28
|
| Rate for Payer: Midlands Choice Commercial |
$23.59
|
| Rate for Payer: United Healthcare Commercial |
$30.33
|
|
