|
sucralfate 1 g Tab [VDMC]
|
Facility
|
OP
|
$2.23
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422727
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| 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: Molina Healthcare Managed Medicare |
$1.13
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.67
|
| 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
|
|
|
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 |
$1.67
|
| Rate for Payer: Medical Associates Commercial |
$1.67
|
| Rate for Payer: Midlands Choice Commercial |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
|
|
sugammadex 100 mg/mL 2 ml SDV [VDMC]
|
Facility
|
IP
|
$489.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15247256
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
sugammadex 100 mg/mL 2 ml SDV [VDMC]
|
Facility
|
OP
|
$489.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
15247256
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$248.16
|
| Rate for Payer: Oscar Health of IA Commercial |
$366.96
|
| 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
|
|
|
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 |
$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: Molina Healthcare Managed Medicare |
$73.85
|
| Rate for Payer: Oscar Health of IA Commercial |
$109.20
|
| 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
|
|
|
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
|
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 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 |
$4.85 |
| 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: Molina Healthcare Managed Medicare |
$4.92
|
| Rate for Payer: Oscar Health of IA Commercial |
$7.28
|
| 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 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 |
$1.04 |
| 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 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 |
$0.74 |
| 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: Molina Healthcare Managed Medicare |
$0.75
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.11
|
| 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 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 |
$43.16 |
| 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 [VDMC]
|
Facility
|
OP
|
$47.95
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
11224670
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$24.32
|
| Rate for Payer: Oscar Health of IA Commercial |
$35.96
|
| 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 [VDMC]
|
Facility
|
IP
|
$1.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422934
|
|
Hospital Revenue Code
|
259
|
| 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 [VDMC]
|
Facility
|
OP
|
$1.55
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10422934
|
|
Hospital Revenue Code
|
259
|
| 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: Molina Healthcare Managed Medicare |
$0.79
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.16
|
| 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
|
|
|
SUMAtriptan 100 mg Tab [VDMC]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna of IA Commercial |
$2.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.66
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.22
|
| Rate for Payer: Medical Associates Commercial |
$2.22
|
| Rate for Payer: Midlands Choice Commercial |
$2.07
|
| Rate for Payer: United Healthcare Commercial |
$2.66
|
|
|
SUMAtriptan 100 mg Tab [VDMC]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10423072
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna of IA Commercial |
$2.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.66
|
| Rate for Payer: Aetna of IA Medicare |
$1.69
|
| Rate for Payer: Amerigroup Medicaid |
$1.49
|
| Rate for Payer: Amerigroup Medicare |
$1.49
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.48
|
| Rate for Payer: Medical Associates Commercial |
$2.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.48
|
| Rate for Payer: Midlands Choice Commercial |
$2.07
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.50
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.50
|
| Rate for Payer: Oscar Health of IA Commercial |
$2.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.22
|
| Rate for Payer: United Healthcare Commercial |
$2.66
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.75
|
|
|
SUMAtriptan 6 mg/0.5 mL SubQ SDV [VDMC]
|
Facility
|
OP
|
$38.30
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
10423141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$34.47 |
| Rate for Payer: Aetna of IA Commercial |
$34.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.47
|
| Rate for Payer: Aetna of IA Medicare |
$21.83
|
| Rate for Payer: Amerigroup Medicaid |
$19.33
|
| Rate for Payer: Amerigroup Medicare |
$19.34
|
| Rate for Payer: Cash Price |
$30.64
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$19.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$19.14
|
| Rate for Payer: Medical Associates Commercial |
$28.72
|
| Rate for Payer: Medical Associates Managed Medicare |
$19.15
|
| Rate for Payer: Midlands Choice Commercial |
$26.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$19.44
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$19.43
|
| Rate for Payer: Oscar Health of IA Commercial |
$28.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$28.72
|
| Rate for Payer: United Healthcare Commercial |
$34.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$22.60
|
|
|
SUMAtriptan 6 mg/0.5 mL SubQ SDV [VDMC]
|
Facility
|
IP
|
$38.30
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
10423141
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.81 |
| Max. Negotiated Rate |
$34.47 |
| Rate for Payer: Aetna of IA Commercial |
$34.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$34.47
|
| Rate for Payer: Cash Price |
$30.64
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$28.72
|
| Rate for Payer: Medical Associates Commercial |
$28.72
|
| Rate for Payer: Midlands Choice Commercial |
$26.81
|
| Rate for Payer: United Healthcare Commercial |
$34.47
|
|
|
SUPPLIES FOR WOUND CARE NON SELECTIVE
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
8013710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.80 |
| Max. Negotiated Rate |
$336.60 |
| Rate for Payer: Aetna of IA Commercial |
$336.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.60
|
| Rate for Payer: Cash Price |
$299.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.50
|
| Rate for Payer: Medical Associates Commercial |
$280.50
|
| Rate for Payer: Midlands Choice Commercial |
$261.80
|
| Rate for Payer: United Healthcare Commercial |
$336.60
|
|
|
SUPPLIES FOR WOUND CARE NON SELECTIVE
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
8013710
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$186.93 |
| Max. Negotiated Rate |
$336.60 |
| Rate for Payer: Aetna of IA Commercial |
$336.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.60
|
| Rate for Payer: Aetna of IA Medicare |
$213.18
|
| Rate for Payer: Amerigroup Medicaid |
$188.76
|
| Rate for Payer: Amerigroup Medicare |
$188.87
|
| Rate for Payer: Cash Price |
$299.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$187.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$186.93
|
| Rate for Payer: Medical Associates Commercial |
$280.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$187.00
|
| Rate for Payer: Midlands Choice Commercial |
$261.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$189.80
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$189.69
|
| Rate for Payer: Oscar Health of IA Commercial |
$280.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$280.50
|
| Rate for Payer: United Healthcare Commercial |
$336.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$220.66
|
|
|
SURETAPE 2-0
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8767795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$51.98 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Aetna of IA Medicare |
$59.28
|
| Rate for Payer: Amerigroup Medicaid |
$52.49
|
| Rate for Payer: Amerigroup Medicare |
$52.52
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$52.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$51.98
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$52.00
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$52.78
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$52.75
|
| Rate for Payer: Oscar Health of IA Commercial |
$78.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$78.00
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.36
|
|
|
SURETAPE 2-0
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8767795
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of IA Commercial |
$93.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$93.60
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.00
|
| Rate for Payer: Medical Associates Commercial |
$78.00
|
| Rate for Payer: Midlands Choice Commercial |
$72.80
|
| Rate for Payer: United Healthcare Commercial |
$93.60
|
|
|
Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous
|
Facility
|
OP
|
$4,960.19
|
|
|
Service Code
|
CPT 46270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,509.26 |
| Max. Negotiated Rate |
$4,960.19 |
| Rate for Payer: Wellmark IA HMO |
$4,509.26
|
| Rate for Payer: Wellmark IA PPO |
$4,960.19
|
|
|
SURGIMESH HERNIA BARRIER MESH VENRAL
|
Facility
|
IP
|
$2,988.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
8046321
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,091.60 |
| Max. Negotiated Rate |
$2,689.20 |
| Rate for Payer: Aetna of IA Commercial |
$2,689.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,689.20
|
| Rate for Payer: Cash Price |
$2,390.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,241.00
|
| Rate for Payer: Medical Associates Commercial |
$2,241.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,091.60
|
| Rate for Payer: United Healthcare Commercial |
$2,689.20
|
|
|
SURGIMESH HERNIA BARRIER MESH VENRAL
|
Facility
|
OP
|
$2,988.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
8046321
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,493.40 |
| Max. Negotiated Rate |
$2,689.20 |
| Rate for Payer: Aetna of IA Commercial |
$2,689.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,689.20
|
| Rate for Payer: Aetna of IA Medicare |
$1,703.16
|
| Rate for Payer: Amerigroup Medicaid |
$1,508.04
|
| Rate for Payer: Amerigroup Medicare |
$1,508.94
|
| Rate for Payer: Cash Price |
$2,390.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,241.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,494.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,493.40
|
| Rate for Payer: Medical Associates Commercial |
$2,241.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,494.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,091.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,516.41
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1,515.51
|
| Rate for Payer: Oscar Health of IA Commercial |
$2,241.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,241.00
|
| Rate for Payer: United Healthcare Commercial |
$2,689.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,762.92
|
|
