|
furosemide 20 mg Tab [VDMC]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna of IA Commercial |
$1.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.46
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.21
|
| Rate for Payer: Medical Associates Commercial |
$1.21
|
| Rate for Payer: Midlands Choice Commercial |
$1.13
|
| Rate for Payer: United Healthcare Commercial |
$1.46
|
|
|
furosemide 20 mg Tab [VDMC]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391344
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna of IA Commercial |
$1.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.46
|
| Rate for Payer: Aetna of IA Medicare |
$0.92
|
| Rate for Payer: Amerigroup Medicaid |
$0.93
|
| Rate for Payer: Amerigroup Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.21
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.93
|
| Rate for Payer: Medical Associates Commercial |
$1.21
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.73
|
| Rate for Payer: Midlands Choice Commercial |
$1.13
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.96
|
|
|
furosemide 40 mg Tab [VDMC]
|
Facility
|
IP
|
$1.69
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of IA Commercial |
$1.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.52
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.27
|
| Rate for Payer: Medical Associates Commercial |
$1.27
|
| Rate for Payer: Midlands Choice Commercial |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
|
|
furosemide 40 mg Tab [VDMC]
|
Facility
|
OP
|
$1.69
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391413
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of IA Commercial |
$1.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.52
|
| Rate for Payer: Aetna of IA Medicare |
$0.97
|
| Rate for Payer: Amerigroup Medicaid |
$0.98
|
| Rate for Payer: Amerigroup Medicare |
$0.77
|
| Rate for Payer: Cash Price |
$1.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.27
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.76
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.97
|
| Rate for Payer: Medical Associates Commercial |
$1.27
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.76
|
| Rate for Payer: Midlands Choice Commercial |
$1.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.00
|
|
|
G0105 Medicare High risk normal screening colonoscopy
|
Professional
|
Both
|
$1,046.00
|
|
|
Service Code
|
CPT G0105
|
| Hospital Charge Code |
8799222
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$366.45 |
| Max. Negotiated Rate |
$784.50 |
| Rate for Payer: Amerigroup Medicaid |
$370.04
|
| Rate for Payer: Cash Price |
$836.80
|
| Rate for Payer: Cash Price |
$836.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$366.45
|
| Rate for Payer: Medical Associates Commercial |
$784.50
|
| Rate for Payer: Midlands Choice Commercial |
$732.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$368.24
|
| Rate for Payer: Partners Health Alliance Commercial |
$784.50
|
| Rate for Payer: United Healthcare Commercial |
$499.18
|
| Rate for Payer: Wellmark IA HMO WHPI |
$647.10
|
| Rate for Payer: Wellmark IA PPO |
$767.30
|
|
|
G0121 COLONOSCOPY SCREENING NON RISK
|
Professional
|
Both
|
$1,049.00
|
|
|
Service Code
|
HCPCS G0121
|
| Hospital Charge Code |
7808122
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$499.68 |
| Max. Negotiated Rate |
$786.75 |
| Rate for Payer: Cash Price |
$839.20
|
| Rate for Payer: Cash Price |
$839.20
|
| Rate for Payer: Medical Associates Commercial |
$786.75
|
| Rate for Payer: Midlands Choice Commercial |
$734.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$786.75
|
| Rate for Payer: United Healthcare Commercial |
$499.68
|
| Rate for Payer: Wellmark IA HMO WHPI |
$647.70
|
| Rate for Payer: Wellmark IA PPO |
$768.10
|
|
|
G0239 Pulmonary Rehab
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
HCPCS G0239
|
| Hospital Charge Code |
5818783
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$185.88 |
| Rate for Payer: Aetna of IA Commercial |
$140.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$140.40
|
| Rate for Payer: Aetna of IA Medicare |
$88.92
|
| Rate for Payer: Amerigroup Medicaid |
$89.98
|
| Rate for Payer: Amerigroup Medicare |
$70.90
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$117.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$70.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.11
|
| Rate for Payer: Medical Associates Commercial |
$117.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$70.20
|
| Rate for Payer: Midlands Choice Commercial |
$109.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$90.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$80.73
|
| Rate for Payer: United Healthcare Commercial |
$140.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$92.04
|
| Rate for Payer: Wellmark IA HMO WHPI |
$168.74
|
| Rate for Payer: Wellmark IA PPO |
$185.88
|
|
|
G0239 Pulmonary Rehab
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
HCPCS G0239
|
| Hospital Charge Code |
5818783
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$140.40 |
| Rate for Payer: Aetna of IA Commercial |
$140.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$140.40
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$117.00
|
| Rate for Payer: Medical Associates Commercial |
$117.00
|
| Rate for Payer: Midlands Choice Commercial |
$109.20
|
| Rate for Payer: United Healthcare Commercial |
$140.40
|
|
|
gabapentin 100 mg Cap [VDMC]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391482
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of IA Commercial |
$1.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.18
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
|
|
gabapentin 100 mg Cap [VDMC]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391482
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of IA Commercial |
$1.18
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.18
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.98
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.75
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.68
|
| Rate for Payer: United Healthcare Commercial |
$1.18
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
gabapentin 250 mg/5 mL Solution[VDMC]
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23101177
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.34 |
| Rate for Payer: Aetna of IA Commercial |
$3.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.34
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.78
|
| Rate for Payer: Medical Associates Commercial |
$2.78
|
| Rate for Payer: Midlands Choice Commercial |
$2.60
|
| Rate for Payer: United Healthcare Commercial |
$3.34
|
|
|
gabapentin 250 mg/5 mL Solution[VDMC]
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
23101177
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$3.34 |
| Rate for Payer: Aetna of IA Commercial |
$3.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.34
|
| Rate for Payer: Aetna of IA Medicare |
$2.12
|
| Rate for Payer: Amerigroup Medicaid |
$2.14
|
| Rate for Payer: Amerigroup Medicare |
$1.69
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.67
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.12
|
| Rate for Payer: Medical Associates Commercial |
$2.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.67
|
| Rate for Payer: Midlands Choice Commercial |
$2.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.15
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.92
|
| Rate for Payer: United Healthcare Commercial |
$3.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.19
|
|
|
gabapentin 300 mg Cap [VDMC]
|
Facility
|
IP
|
$1.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391549
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of IA Commercial |
$1.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.23
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.02
|
| Rate for Payer: Medical Associates Commercial |
$1.02
|
| Rate for Payer: Midlands Choice Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
|
|
gabapentin 300 mg Cap [VDMC]
|
Facility
|
OP
|
$1.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10391549
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of IA Commercial |
$1.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.23
|
| Rate for Payer: Aetna of IA Medicare |
$0.78
|
| Rate for Payer: Amerigroup Medicaid |
$0.79
|
| Rate for Payer: Amerigroup Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.09
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.78
|
| Rate for Payer: Medical Associates Commercial |
$1.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.61
|
| Rate for Payer: Midlands Choice Commercial |
$0.95
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.71
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.80
|
|
|
GAIT THERAPEUTIC TRAINING PER 15 MIN
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 97116 GP
|
| Hospital Charge Code |
1374013
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
GAIT THERAPEUTIC TRAINING PER 15 MIN
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 97116 GP
|
| Hospital Charge Code |
1374013
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$51.30 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$65.76
|
| Rate for Payer: Amerigroup Medicare |
$51.81
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.12
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.30
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$59.00
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
| Rate for Payer: Wellmark IA HMO WHPI |
$73.74
|
| Rate for Payer: Wellmark IA PPO |
$81.22
|
|
|
Gastrointestinal Basic Bacteria by PCR DMCL
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
CPT 87505
|
| Hospital Charge Code |
8984516
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$152.10 |
| Max. Negotiated Rate |
$317.09 |
| Rate for Payer: Aetna of IA Commercial |
$304.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$304.20
|
| Rate for Payer: Aetna of IA Medicare |
$192.66
|
| Rate for Payer: Amerigroup Medicaid |
$194.96
|
| Rate for Payer: Amerigroup Medicare |
$153.62
|
| Rate for Payer: Cash Price |
$270.40
|
| Rate for Payer: Cash Price |
$270.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$253.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$152.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$193.07
|
| Rate for Payer: Medical Associates Commercial |
$253.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$152.10
|
| Rate for Payer: Midlands Choice Commercial |
$236.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$195.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$174.92
|
| Rate for Payer: United Healthcare Commercial |
$304.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$199.42
|
| Rate for Payer: Wellmark IA HMO WHPI |
$287.85
|
| Rate for Payer: Wellmark IA PPO |
$317.09
|
|
|
Gastrointestinal Basic Bacteria by PCR DMCL
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
CPT 87505
|
| Hospital Charge Code |
8984516
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$236.60 |
| Max. Negotiated Rate |
$304.20 |
| Rate for Payer: Aetna of IA Commercial |
$304.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$304.20
|
| Rate for Payer: Cash Price |
$270.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$253.50
|
| Rate for Payer: Medical Associates Commercial |
$253.50
|
| Rate for Payer: Midlands Choice Commercial |
$236.60
|
| Rate for Payer: United Healthcare Commercial |
$304.20
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH CC
|
Facility
|
IP
|
$10,413.04
|
|
|
Service Code
|
MSDRG 378
|
| Min. Negotiated Rate |
$10,262.12 |
| Max. Negotiated Rate |
$10,413.04 |
| Rate for Payer: Amerigroup Medicaid |
$10,362.73
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10,262.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,413.04
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH MCC
|
Facility
|
IP
|
$15,888.66
|
|
|
Service Code
|
MSDRG 377
|
| Min. Negotiated Rate |
$15,658.38 |
| Max. Negotiated Rate |
$15,888.66 |
| Rate for Payer: Amerigroup Medicaid |
$15,811.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15,658.38
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15,888.66
|
|
|
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC
|
Facility
|
IP
|
$6,612.86
|
|
|
Service Code
|
MSDRG 379
|
| Min. Negotiated Rate |
$6,517.02 |
| Max. Negotiated Rate |
$6,612.86 |
| Rate for Payer: Amerigroup Medicaid |
$6,580.91
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,517.02
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,612.86
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH CC
|
Facility
|
IP
|
$8,630.61
|
|
|
Service Code
|
MSDRG 389
|
| Min. Negotiated Rate |
$8,505.53 |
| Max. Negotiated Rate |
$8,630.61 |
| Rate for Payer: Amerigroup Medicaid |
$8,588.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,505.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,630.61
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH MCC
|
Facility
|
IP
|
$11,358.86
|
|
|
Service Code
|
MSDRG 388
|
| Min. Negotiated Rate |
$11,194.23 |
| Max. Negotiated Rate |
$11,358.86 |
| Rate for Payer: Amerigroup Medicaid |
$11,303.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11,194.23
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11,358.86
|
|
|
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC
|
Facility
|
IP
|
$5,905.75
|
|
|
Service Code
|
MSDRG 390
|
| Min. Negotiated Rate |
$5,820.16 |
| Max. Negotiated Rate |
$5,905.75 |
| Rate for Payer: Amerigroup Medicaid |
$5,877.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$5,820.16
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,905.75
|
|
|
Gastrointestinal Panel by PCR DMCL
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
CPT 87507
|
| Hospital Charge Code |
8505666
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Aetna of IA Commercial |
$675.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$675.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$562.50
|
| Rate for Payer: Medical Associates Commercial |
$562.50
|
| Rate for Payer: Midlands Choice Commercial |
$525.00
|
| Rate for Payer: United Healthcare Commercial |
$675.00
|
|
