|
cefepime 2 g SDV
|
Facility
IP
|
$36.37
|
|
|
Service Code
|
CPT J0692
|
| Hospital Charge Code |
43700240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.46 |
| Max. Negotiated Rate |
$32.73 |
| Rate for Payer: Aetna of IA Commercial |
$32.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.73
|
| Rate for Payer: Cash Price |
$29.10
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$27.28
|
| Rate for Payer: Medical Associates Commercial |
$27.28
|
| Rate for Payer: Midlands Choice Commercial |
$25.46
|
| Rate for Payer: United Healthcare Commercial |
$32.73
|
|
|
cefoTEtan 1 g/50 mL-iso-osmotic dextrose IV Sol SDV
|
Facility
OP
|
$101.50
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.73 |
| Max. Negotiated Rate |
$91.35 |
| Rate for Payer: Aetna of IA Commercial |
$91.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$91.35
|
| Rate for Payer: Aetna of IA Medicare |
$57.86
|
| Rate for Payer: Amerigroup Medicaid |
$51.23
|
| Rate for Payer: Amerigroup Medicare |
$51.26
|
| Rate for Payer: Cash Price |
$81.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$76.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$50.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$50.73
|
| Rate for Payer: Medical Associates Commercial |
$76.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$50.75
|
| Rate for Payer: Midlands Choice Commercial |
$71.05
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$51.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$76.12
|
| Rate for Payer: United Healthcare Commercial |
$91.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$59.88
|
|
|
cefoTEtan 1 g/50 mL-iso-osmotic dextrose IV Sol SDV
|
Facility
IP
|
$101.50
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$91.35 |
| Rate for Payer: Aetna of IA Commercial |
$91.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$91.35
|
| Rate for Payer: Cash Price |
$81.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$76.12
|
| Rate for Payer: Medical Associates Commercial |
$76.12
|
| Rate for Payer: Midlands Choice Commercial |
$71.05
|
| Rate for Payer: United Healthcare Commercial |
$91.35
|
|
|
cefoTEtan 1 g Inj SDV
|
Facility
IP
|
$53.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.52 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Aetna of IA Commercial |
$48.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.24
|
| Rate for Payer: Cash Price |
$42.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.20
|
| Rate for Payer: Medical Associates Commercial |
$40.20
|
| Rate for Payer: Midlands Choice Commercial |
$37.52
|
| Rate for Payer: United Healthcare Commercial |
$48.24
|
|
|
cefoTEtan 1 g Inj SDV
|
Facility
OP
|
$53.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$48.24 |
| Rate for Payer: Aetna of IA Commercial |
$48.24
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$48.24
|
| Rate for Payer: Aetna of IA Medicare |
$30.55
|
| Rate for Payer: Amerigroup Medicaid |
$27.05
|
| Rate for Payer: Amerigroup Medicare |
$27.07
|
| Rate for Payer: Cash Price |
$42.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$40.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.79
|
| Rate for Payer: Medical Associates Commercial |
$40.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.80
|
| Rate for Payer: Midlands Choice Commercial |
$37.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$40.20
|
| Rate for Payer: United Healthcare Commercial |
$48.24
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.62
|
|
|
cefOXitin 2 g Inj SDV
|
Facility
IP
|
$41.49
|
|
|
Service Code
|
CPT J0694
|
| Hospital Charge Code |
43700236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.04 |
| Max. Negotiated Rate |
$37.34 |
| Rate for Payer: Aetna of IA Commercial |
$37.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.34
|
| Rate for Payer: Cash Price |
$33.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.12
|
| Rate for Payer: Medical Associates Commercial |
$31.12
|
| Rate for Payer: Midlands Choice Commercial |
$29.04
|
| Rate for Payer: United Healthcare Commercial |
$37.34
|
|
|
cefOXitin 2 g Inj SDV
|
Facility
OP
|
$41.49
|
|
|
Service Code
|
CPT J0694
|
| Hospital Charge Code |
43700236
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.74 |
| Max. Negotiated Rate |
$37.34 |
| Rate for Payer: Aetna of IA Commercial |
$37.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.34
|
| Rate for Payer: Aetna of IA Medicare |
$23.65
|
| Rate for Payer: Amerigroup Medicaid |
$20.94
|
| Rate for Payer: Amerigroup Medicare |
$20.95
|
| Rate for Payer: Cash Price |
$33.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.74
|
| Rate for Payer: Medical Associates Commercial |
$31.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.74
|
| Rate for Payer: Midlands Choice Commercial |
$29.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.12
|
| Rate for Payer: United Healthcare Commercial |
$37.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.48
|
|
|
cefprozil 250 mg/5 mL Pow 50ml susp
|
Facility
OP
|
$124.28
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.12 |
| Max. Negotiated Rate |
$111.85 |
| Rate for Payer: Aetna of IA Commercial |
$111.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$111.85
|
| Rate for Payer: Aetna of IA Medicare |
$70.84
|
| Rate for Payer: Amerigroup Medicaid |
$62.72
|
| Rate for Payer: Amerigroup Medicare |
$62.76
|
| Rate for Payer: Cash Price |
$99.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$93.21
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$62.14
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.12
|
| Rate for Payer: Medical Associates Commercial |
$93.21
|
| Rate for Payer: Medical Associates Managed Medicare |
$62.14
|
| Rate for Payer: Midlands Choice Commercial |
$87.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$63.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.21
|
| Rate for Payer: United Healthcare Commercial |
$111.85
|
| Rate for Payer: United Healthcare Managed Medicare |
$73.33
|
|
|
cefprozil 250 mg/5 mL Pow 50ml susp
|
Facility
IP
|
$124.28
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.00 |
| Max. Negotiated Rate |
$111.85 |
| Rate for Payer: Aetna of IA Commercial |
$111.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$111.85
|
| Rate for Payer: Cash Price |
$99.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$93.21
|
| Rate for Payer: Medical Associates Commercial |
$93.21
|
| Rate for Payer: Midlands Choice Commercial |
$87.00
|
| Rate for Payer: United Healthcare Commercial |
$111.85
|
|
|
ceftaroline fosamil 600 mg SDV Pow
|
Facility
IP
|
$648.19
|
|
|
Service Code
|
CPT J0712
|
| Hospital Charge Code |
43700218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$453.73 |
| Max. Negotiated Rate |
$583.37 |
| Rate for Payer: Aetna of IA Commercial |
$583.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$583.37
|
| Rate for Payer: Cash Price |
$518.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$486.14
|
| Rate for Payer: Medical Associates Commercial |
$486.14
|
| Rate for Payer: Midlands Choice Commercial |
$453.73
|
| Rate for Payer: United Healthcare Commercial |
$583.37
|
|
|
ceftaroline fosamil 600 mg SDV Pow
|
Facility
OP
|
$648.19
|
|
|
Service Code
|
CPT J0712
|
| Hospital Charge Code |
43700218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$323.97 |
| Max. Negotiated Rate |
$583.37 |
| Rate for Payer: Aetna of IA Commercial |
$583.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$583.37
|
| Rate for Payer: Aetna of IA Medicare |
$369.47
|
| Rate for Payer: Amerigroup Medicaid |
$327.14
|
| Rate for Payer: Amerigroup Medicare |
$327.34
|
| Rate for Payer: Cash Price |
$518.55
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$486.14
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$324.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$323.97
|
| Rate for Payer: Medical Associates Commercial |
$486.14
|
| Rate for Payer: Medical Associates Managed Medicare |
$324.10
|
| Rate for Payer: Midlands Choice Commercial |
$453.73
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$328.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$486.14
|
| Rate for Payer: United Healthcare Commercial |
$583.37
|
| Rate for Payer: United Healthcare Managed Medicare |
$382.43
|
|
|
cefTAZidime 1 g Inj SDV
|
Facility
OP
|
$30.75
|
|
|
Service Code
|
CPT J0713
|
| Hospital Charge Code |
43701872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.37 |
| Max. Negotiated Rate |
$27.68 |
| Rate for Payer: Aetna of IA Commercial |
$27.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.68
|
| Rate for Payer: Aetna of IA Medicare |
$17.53
|
| Rate for Payer: Amerigroup Medicaid |
$15.52
|
| Rate for Payer: Amerigroup Medicare |
$15.53
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.37
|
| Rate for Payer: Medical Associates Commercial |
$23.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.38
|
| Rate for Payer: Midlands Choice Commercial |
$21.52
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.06
|
| Rate for Payer: United Healthcare Commercial |
$27.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.14
|
|
|
cefTAZidime 1 g Inj SDV
|
Facility
IP
|
$30.75
|
|
|
Service Code
|
CPT J0713
|
| Hospital Charge Code |
43701872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.52 |
| Max. Negotiated Rate |
$27.68 |
| Rate for Payer: Aetna of IA Commercial |
$27.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$27.68
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.06
|
| Rate for Payer: Medical Associates Commercial |
$23.06
|
| Rate for Payer: Midlands Choice Commercial |
$21.52
|
| Rate for Payer: United Healthcare Commercial |
$27.68
|
|
|
cefTAZidime 2 g Inj SDV
|
Facility
OP
|
$42.22
|
|
|
Service Code
|
CPT J0713
|
| Hospital Charge Code |
43703489
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.10 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Aetna of IA Commercial |
$38.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.00
|
| Rate for Payer: Aetna of IA Medicare |
$24.07
|
| Rate for Payer: Amerigroup Medicaid |
$21.31
|
| Rate for Payer: Amerigroup Medicare |
$21.32
|
| Rate for Payer: Cash Price |
$33.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.66
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.11
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.10
|
| Rate for Payer: Medical Associates Commercial |
$31.66
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.11
|
| Rate for Payer: Midlands Choice Commercial |
$29.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.43
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.66
|
| Rate for Payer: United Healthcare Commercial |
$38.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.91
|
|
|
cefTAZidime 2 g Inj SDV
|
Facility
IP
|
$42.22
|
|
|
Service Code
|
CPT J0713
|
| Hospital Charge Code |
43703489
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.55 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: Aetna of IA Commercial |
$38.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.00
|
| Rate for Payer: Cash Price |
$33.77
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.66
|
| Rate for Payer: Medical Associates Commercial |
$31.66
|
| Rate for Payer: Midlands Choice Commercial |
$29.55
|
| Rate for Payer: United Healthcare Commercial |
$38.00
|
|
|
cefTRIAXone 1 g Inj SDV
|
Facility
IP
|
$24.86
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
43701058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.40 |
| Max. Negotiated Rate |
$22.37 |
| Rate for Payer: Aetna of IA Commercial |
$22.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.37
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.64
|
| Rate for Payer: Medical Associates Commercial |
$18.64
|
| Rate for Payer: Midlands Choice Commercial |
$17.40
|
| Rate for Payer: United Healthcare Commercial |
$22.37
|
|
|
cefTRIAXone 1 g Inj SDV
|
Facility
OP
|
$24.86
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
43701058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$22.37 |
| Rate for Payer: Aetna of IA Commercial |
$22.37
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.37
|
| Rate for Payer: Aetna of IA Medicare |
$14.17
|
| Rate for Payer: Amerigroup Medicaid |
$12.55
|
| Rate for Payer: Amerigroup Medicare |
$12.55
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.43
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.43
|
| Rate for Payer: Medical Associates Commercial |
$18.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.43
|
| Rate for Payer: Midlands Choice Commercial |
$17.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$22.37
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.67
|
|
|
cefTRIAXone 250 mg Inj SDV
|
Facility
OP
|
$24.91
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
43701054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna of IA Commercial |
$22.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.42
|
| Rate for Payer: Aetna of IA Medicare |
$14.20
|
| Rate for Payer: Amerigroup Medicaid |
$12.57
|
| Rate for Payer: Amerigroup Medicare |
$12.58
|
| Rate for Payer: Cash Price |
$19.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.46
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.45
|
| Rate for Payer: Medical Associates Commercial |
$18.68
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.46
|
| Rate for Payer: Midlands Choice Commercial |
$17.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.68
|
| Rate for Payer: United Healthcare Commercial |
$22.42
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.70
|
|
|
cefTRIAXone 250 mg Inj SDV
|
Facility
IP
|
$24.91
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
43701054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna of IA Commercial |
$22.42
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.42
|
| Rate for Payer: Cash Price |
$19.93
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.68
|
| Rate for Payer: Medical Associates Commercial |
$18.68
|
| Rate for Payer: Midlands Choice Commercial |
$17.44
|
| Rate for Payer: United Healthcare Commercial |
$22.42
|
|
|
cefTRIAXone 2 g Inj SDV
|
Facility
OP
|
$25.65
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
43706104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.82 |
| Max. Negotiated Rate |
$23.08 |
| Rate for Payer: Aetna of IA Commercial |
$23.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.08
|
| Rate for Payer: Aetna of IA Medicare |
$14.62
|
| Rate for Payer: Amerigroup Medicaid |
$12.95
|
| Rate for Payer: Amerigroup Medicare |
$12.95
|
| Rate for Payer: Cash Price |
$20.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.82
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.82
|
| Rate for Payer: Medical Associates Commercial |
$19.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.82
|
| Rate for Payer: Midlands Choice Commercial |
$17.96
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare Commercial |
$23.08
|
| Rate for Payer: United Healthcare Managed Medicare |
$15.13
|
|
|
cefTRIAXone 2 g Inj SDV
|
Facility
IP
|
$25.65
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
43706104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$23.08 |
| Rate for Payer: Aetna of IA Commercial |
$23.08
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$23.08
|
| Rate for Payer: Cash Price |
$20.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$19.24
|
| Rate for Payer: Medical Associates Commercial |
$19.24
|
| Rate for Payer: Midlands Choice Commercial |
$17.96
|
| Rate for Payer: United Healthcare Commercial |
$23.08
|
|
|
cefTRIAXone 500 mg Inj SDV
|
Facility
OP
|
$23.86
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
43701056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$21.47 |
| Rate for Payer: Aetna of IA Commercial |
$21.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.47
|
| Rate for Payer: Aetna of IA Medicare |
$13.60
|
| Rate for Payer: Amerigroup Medicaid |
$12.04
|
| Rate for Payer: Amerigroup Medicare |
$12.05
|
| Rate for Payer: Cash Price |
$19.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.93
|
| Rate for Payer: Medical Associates Commercial |
$17.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.93
|
| Rate for Payer: Midlands Choice Commercial |
$16.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.90
|
| Rate for Payer: United Healthcare Commercial |
$21.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.08
|
|
|
cefTRIAXone 500 mg Inj SDV
|
Facility
IP
|
$23.86
|
|
|
Service Code
|
CPT J0696
|
| Hospital Charge Code |
43701056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.70 |
| Max. Negotiated Rate |
$21.47 |
| Rate for Payer: Aetna of IA Commercial |
$21.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.47
|
| Rate for Payer: Cash Price |
$19.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.90
|
| Rate for Payer: Medical Associates Commercial |
$17.90
|
| Rate for Payer: Midlands Choice Commercial |
$16.70
|
| Rate for Payer: United Healthcare Commercial |
$21.47
|
|
|
cefuroxime 250 mg/5 mL 50 ml Pow
|
Facility
OP
|
$405.20
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.52 |
| Max. Negotiated Rate |
$364.68 |
| Rate for Payer: Aetna of IA Commercial |
$364.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$364.68
|
| Rate for Payer: Aetna of IA Medicare |
$230.96
|
| Rate for Payer: Amerigroup Medicaid |
$204.50
|
| Rate for Payer: Amerigroup Medicare |
$204.63
|
| Rate for Payer: Cash Price |
$324.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$303.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$202.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$202.52
|
| Rate for Payer: Medical Associates Commercial |
$303.90
|
| Rate for Payer: Medical Associates Managed Medicare |
$202.60
|
| Rate for Payer: Midlands Choice Commercial |
$283.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$205.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$303.90
|
| Rate for Payer: United Healthcare Commercial |
$364.68
|
| Rate for Payer: United Healthcare Managed Medicare |
$239.07
|
|
|
cefuroxime 250 mg/5 mL 50 ml Pow
|
Facility
IP
|
$405.20
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700039
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$283.64 |
| Max. Negotiated Rate |
$364.68 |
| Rate for Payer: Aetna of IA Commercial |
$364.68
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$364.68
|
| Rate for Payer: Cash Price |
$324.16
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$303.90
|
| Rate for Payer: Medical Associates Commercial |
$303.90
|
| Rate for Payer: Midlands Choice Commercial |
$283.64
|
| Rate for Payer: United Healthcare Commercial |
$364.68
|
|
