|
STRAPPING TOES
|
Facility
OP
|
$94.00
|
|
|
Service Code
|
CPT 29550 GP
|
| Hospital Charge Code |
1374358
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$46.98 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna of IA Commercial |
$84.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$84.60
|
| Rate for Payer: Aetna of IA Medicare |
$53.58
|
| Rate for Payer: Amerigroup Medicaid |
$47.44
|
| Rate for Payer: Amerigroup Medicare |
$47.47
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$70.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$47.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$46.98
|
| Rate for Payer: Medical Associates Commercial |
$70.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$47.00
|
| Rate for Payer: Midlands Choice Commercial |
$65.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$47.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$70.50
|
| Rate for Payer: United Healthcare Commercial |
$84.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$55.46
|
|
|
STREP A TEST, THROAT
|
Facility
OP
|
$49.00
|
|
|
Service Code
|
CPT 87880
|
| Hospital Charge Code |
633913
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$24.49 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna of IA Commercial |
$44.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.10
|
| Rate for Payer: Aetna of IA Medicare |
$27.93
|
| Rate for Payer: Amerigroup Medicaid |
$24.73
|
| Rate for Payer: Amerigroup Medicare |
$24.74
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.49
|
| Rate for Payer: Medical Associates Commercial |
$36.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.50
|
| Rate for Payer: Midlands Choice Commercial |
$34.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$36.75
|
| Rate for Payer: United Healthcare Commercial |
$44.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.91
|
| Rate for Payer: Wellmark IA HMO |
$31.00
|
| Rate for Payer: Wellmark IA PPO |
$34.10
|
|
|
STREP A TEST, THROAT
|
Facility
IP
|
$49.00
|
|
|
Service Code
|
CPT 87880
|
| Hospital Charge Code |
633913
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna of IA Commercial |
$44.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.10
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$36.75
|
| Rate for Payer: Medical Associates Commercial |
$36.75
|
| Rate for Payer: Midlands Choice Commercial |
$34.30
|
| Rate for Payer: United Healthcare Commercial |
$44.10
|
|
|
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
|
|
|
STRESS TEST
|
Facility
OP
|
$738.00
|
|
|
Service Code
|
CPT 93017
|
| Hospital Charge Code |
8012934
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$368.85 |
| 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: Aetna of IA Medicare |
$420.66
|
| Rate for Payer: Amerigroup Medicaid |
$372.47
|
| Rate for Payer: Amerigroup Medicare |
$372.69
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$553.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$369.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$368.85
|
| Rate for Payer: Medical Associates Commercial |
$553.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$369.00
|
| Rate for Payer: Midlands Choice Commercial |
$516.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$374.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$553.50
|
| Rate for Payer: United Healthcare Commercial |
$664.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$435.42
|
| Rate for Payer: Wellmark IA HMO |
$403.62
|
| Rate for Payer: Wellmark IA PPO |
$443.98
|
|
|
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 |
$335.37 |
| Max. Negotiated Rate |
$3,510.94 |
| 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 |
$338.65
|
| Rate for Payer: Amerigroup Medicare |
$338.86
|
| Rate for Payer: Cash Price |
$536.80
|
| 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 |
$335.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$335.37
|
| Rate for Payer: Medical Associates Commercial |
$503.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$335.50
|
| Rate for Payer: Midlands Choice Commercial |
$469.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$340.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$503.25
|
| Rate for Payer: United Healthcare Commercial |
$603.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$395.89
|
| Rate for Payer: Wellmark IA HMO |
$3,191.76
|
| Rate for Payer: Wellmark IA PPO |
$3,510.94
|
|
|
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
|
Facility
OP
|
$29.42
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701800
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.70 |
| 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 |
$14.85
|
| Rate for Payer: Amerigroup Medicare |
$14.86
|
| 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 |
$14.71
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.70
|
| Rate for Payer: Medical Associates Commercial |
$22.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.71
|
| Rate for Payer: Midlands Choice Commercial |
$20.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.06
|
| Rate for Payer: United Healthcare Commercial |
$26.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.36
|
|
|
succinylcholine 20 mg/mL 10ml MDV Inj Sol
|
Facility
IP
|
$29.42
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701800
|
|
Hospital Revenue Code
|
637
|
| 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
|
|
|
sucralfate 1 g/10 mL Oral Susp
|
Facility
IP
|
$29.64
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700188
|
|
Hospital Revenue Code
|
636
|
| 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/10 mL Oral Susp
|
Facility
OP
|
$29.64
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.81 |
| 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 |
$16.89
|
| Rate for Payer: Amerigroup Medicaid |
$14.96
|
| Rate for Payer: Amerigroup Medicare |
$14.97
|
| 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 |
$14.82
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.81
|
| Rate for Payer: Medical Associates Commercial |
$22.23
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.82
|
| Rate for Payer: Midlands Choice Commercial |
$20.75
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.23
|
| Rate for Payer: United Healthcare Commercial |
$26.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.49
|
|
|
sucralfate 1 g Tab
|
Facility
IP
|
$2.23
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700172
|
|
Hospital Revenue Code
|
637
|
| 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 |
$1.67
|
| Rate for Payer: Medical Associates Commercial |
$1.67
|
| Rate for Payer: Midlands Choice Commercial |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
|
|
sucralfate 1 g Tab
|
Facility
OP
|
$2.23
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| 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 |
$1.13
|
| Rate for Payer: Amerigroup Medicare |
$1.13
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.67
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.11
|
| Rate for Payer: Medical Associates Commercial |
$1.67
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.67
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.32
|
|
|
sugammadex 100 mg/mL 2 ml SDV
|
Facility
OP
|
$489.28
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43709230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$244.54 |
| Max. Negotiated Rate |
$440.35 |
| Rate for Payer: Aetna of IA Commercial |
$440.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$440.35
|
| Rate for Payer: Aetna of IA Medicare |
$278.89
|
| Rate for Payer: Amerigroup Medicaid |
$246.94
|
| Rate for Payer: Amerigroup Medicare |
$247.09
|
| Rate for Payer: Cash Price |
$391.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$366.96
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$244.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$244.54
|
| Rate for Payer: Medical Associates Commercial |
$366.96
|
| Rate for Payer: Medical Associates Managed Medicare |
$244.64
|
| Rate for Payer: Midlands Choice Commercial |
$342.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$248.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$366.96
|
| Rate for Payer: United Healthcare Commercial |
$440.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$288.68
|
|
|
sugammadex 100 mg/mL 2 ml SDV
|
Facility
IP
|
$489.28
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43709230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$342.50 |
| Max. Negotiated Rate |
$440.35 |
| Rate for Payer: Aetna of IA Commercial |
$440.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$440.35
|
| Rate for Payer: Cash Price |
$391.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$366.96
|
| Rate for Payer: Medical Associates Commercial |
$366.96
|
| Rate for Payer: Midlands Choice Commercial |
$342.50
|
| Rate for Payer: United Healthcare Commercial |
$440.35
|
|
|
Sulfacetamide Sodium Opht10% Sol 15 ml
|
Facility
IP
|
$145.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700054
|
|
Hospital Revenue Code
|
637
|
| 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
|
|
|
Sulfacetamide Sodium Opht10% Sol 15 ml
|
Facility
OP
|
$145.60
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700054
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.77 |
| 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 |
$73.48
|
| Rate for Payer: Amerigroup Medicare |
$73.53
|
| 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 |
$72.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.77
|
| Rate for Payer: Medical Associates Commercial |
$109.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$72.80
|
| Rate for Payer: Midlands Choice Commercial |
$101.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$73.89
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.20
|
| Rate for Payer: United Healthcare Commercial |
$131.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$85.90
|
|
|
sulfamethoxazole-trimethoprim
|
Facility
OP
|
$9.70
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.85 |
| 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 |
$4.90
|
| Rate for Payer: Amerigroup Medicare |
$4.90
|
| 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 |
$4.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.85
|
| Rate for Payer: Medical Associates Commercial |
$7.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.85
|
| Rate for Payer: Midlands Choice Commercial |
$6.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.28
|
| Rate for Payer: United Healthcare Commercial |
$8.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.72
|
|
|
sulfamethoxazole-trimethoprim
|
Facility
IP
|
$9.70
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702300
|
|
Hospital Revenue Code
|
636
|
| 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
|
Facility
OP
|
$1.48
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.74 |
| 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 |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.75
|
| 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 |
$0.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.74
|
| Rate for Payer: Medical Associates Commercial |
$1.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.74
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.87
|
|
|
sulfamethoxazole-trimethoprim 800 mg-160 mg Tab
|
Facility
IP
|
$1.48
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| 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 |
$1.04
|
| Rate for Payer: United Healthcare Commercial |
$1.33
|
|
|
sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol
|
Facility
IP
|
$47.95
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.56 |
| Max. Negotiated Rate |
$43.16 |
| Rate for Payer: Aetna of IA Commercial |
$43.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.16
|
| 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 |
$43.16
|
|
|
sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol
|
Facility
OP
|
$47.95
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.97 |
| Max. Negotiated Rate |
$43.16 |
| Rate for Payer: Aetna of IA Commercial |
$43.16
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$43.16
|
| Rate for Payer: Aetna of IA Medicare |
$27.33
|
| Rate for Payer: Amerigroup Medicaid |
$24.20
|
| Rate for Payer: Amerigroup Medicare |
$24.21
|
| 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 |
$23.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23.97
|
| Rate for Payer: Medical Associates Commercial |
$35.96
|
| Rate for Payer: Medical Associates Managed Medicare |
$23.98
|
| Rate for Payer: Midlands Choice Commercial |
$33.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$35.96
|
| Rate for Payer: United Healthcare Commercial |
$43.16
|
| Rate for Payer: United Healthcare Managed Medicare |
$28.29
|
|
|
sulfaSALAzine 500 mg Tab
|
Facility
IP
|
$1.55
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Aetna of IA Commercial |
$1.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.40
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.16
|
| Rate for Payer: Medical Associates Commercial |
$1.16
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
|
|
sulfaSALAzine 500 mg Tab
|
Facility
OP
|
$1.55
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Aetna of IA Commercial |
$1.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.40
|
| Rate for Payer: Aetna of IA Medicare |
$0.88
|
| Rate for Payer: Amerigroup Medicaid |
$0.78
|
| Rate for Payer: Amerigroup Medicare |
$0.78
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.16
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.78
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.77
|
| Rate for Payer: Medical Associates Commercial |
$1.16
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.78
|
| Rate for Payer: Midlands Choice Commercial |
$1.08
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.91
|
|
