|
LEVEL 2
|
Facility
IP
|
$249.00
|
|
|
Service Code
|
CPT 99282 25
|
| Hospital Charge Code |
6922786
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$174.30 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna of IA Commercial |
$224.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$224.10
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$186.75
|
| Rate for Payer: Medical Associates Commercial |
$186.75
|
| Rate for Payer: Midlands Choice Commercial |
$174.30
|
| Rate for Payer: United Healthcare Commercial |
$224.10
|
|
|
Level 2: Extreme Immaturity or Respiratory Distress Syndrome, Neonate
|
Facility
IP
|
$37,846.06
|
|
|
Service Code
|
MS-DRG 7902
|
| Hospital Charge Code |
680
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$37,846.06 |
| Rate for Payer: Amerigroup Medicaid |
$37,663.23
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$37,297.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37,846.06
|
|
|
Level 2: Full Term Neonate W Major Problems
|
Facility
IP
|
$8,531.40
|
|
|
Service Code
|
MS-DRG 7932
|
| Hospital Charge Code |
686
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$8,531.40 |
| Rate for Payer: Amerigroup Medicaid |
$8,490.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,407.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,531.40
|
|
|
Level 2: Neonates, Died or Transferred to Another Acute Care Facility
|
Facility
IP
|
$4,972.39
|
|
|
Service Code
|
MS-DRG 7892
|
| Hospital Charge Code |
678
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$4,972.39 |
| Rate for Payer: Amerigroup Medicaid |
$4,948.37
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4,900.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,972.39
|
|
|
Level 2: Neonate W Other Significant Problems
|
Facility
IP
|
$3,267.68
|
|
|
Service Code
|
MS-DRG 7942
|
| Hospital Charge Code |
688
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$3,267.68 |
| Rate for Payer: Amerigroup Medicaid |
$3,251.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,220.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,267.68
|
|
|
Level 2: Normal Newborn
|
Facility
IP
|
$2,844.46
|
|
|
Service Code
|
MS-DRG 7952
|
| Hospital Charge Code |
690
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$2,844.46 |
| Rate for Payer: Amerigroup Medicaid |
$2,830.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,803.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,844.46
|
|
|
Level 2: Prematurity W Major Problems
|
Facility
IP
|
$22,264.53
|
|
|
Service Code
|
MS-DRG 7912
|
| Hospital Charge Code |
682
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$22,264.53 |
| Rate for Payer: Amerigroup Medicaid |
$22,156.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21,941.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22,264.53
|
|
|
Level 2: Prematurity W/O Major Problems
|
Facility
IP
|
$8,352.27
|
|
|
Service Code
|
MS-DRG 7922
|
| Hospital Charge Code |
684
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$8,352.27 |
| Rate for Payer: Amerigroup Medicaid |
$8,311.92
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,231.23
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,352.27
|
|
|
LEVEL 3
|
Facility
OP
|
$438.00
|
|
|
Service Code
|
CPT 99283 25
|
| Hospital Charge Code |
6922787
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$218.91 |
| Max. Negotiated Rate |
$394.20 |
| Rate for Payer: Aetna of IA Commercial |
$394.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$394.20
|
| Rate for Payer: Aetna of IA Medicare |
$249.66
|
| Rate for Payer: Amerigroup Medicaid |
$221.06
|
| Rate for Payer: Amerigroup Medicare |
$221.19
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$328.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$219.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$218.91
|
| Rate for Payer: Medical Associates Commercial |
$328.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$219.00
|
| Rate for Payer: Midlands Choice Commercial |
$306.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$222.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$328.50
|
| Rate for Payer: United Healthcare Commercial |
$394.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$258.42
|
|
|
LEVEL 3
|
Facility
IP
|
$438.00
|
|
|
Service Code
|
CPT 99283 25
|
| Hospital Charge Code |
6922787
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$306.60 |
| Max. Negotiated Rate |
$394.20 |
| Rate for Payer: Medical Associates Commercial |
$328.50
|
| Rate for Payer: Aetna of IA Commercial |
$394.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$394.20
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$328.50
|
| Rate for Payer: Midlands Choice Commercial |
$306.60
|
| Rate for Payer: United Healthcare Commercial |
$394.20
|
|
|
LEVEL 3
|
Professional
|
$189.00
|
|
|
Service Code
|
CPT 99283
|
| Hospital Charge Code |
7982753
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$65.10 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna of IA Medicare |
$65.10
|
| Rate for Payer: Amerigroup Medicaid |
$67.31
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.12
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$66.40
|
| Rate for Payer: Medical Associates Commercial |
$123.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.10
|
| Rate for Payer: Midlands Choice Commercial |
$132.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$97.65
|
| Rate for Payer: United Healthcare Commercial |
$82.88
|
| Rate for Payer: Wellmark IA HMO |
$112.00
|
| Rate for Payer: Wellmark IA PPO |
$112.00
|
|
|
Level 3: Extreme Immaturity or Respiratory Distress Syndrome, Neonate
|
Facility
IP
|
$83,733.36
|
|
|
Service Code
|
MS-DRG 7907
|
| Hospital Charge Code |
681
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$83,733.36 |
| Rate for Payer: Amerigroup Medicaid |
$83,328.85
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$82,519.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$83,733.36
|
|
|
Level 3: Full Term Neonate W Major Problems
|
Facility
IP
|
$13,929.97
|
|
|
Service Code
|
MS-DRG 7937
|
| Hospital Charge Code |
687
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$13,929.97 |
| Rate for Payer: Amerigroup Medicaid |
$13,862.68
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13,728.09
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13,929.97
|
|
|
Level 3: Neonates, Died or Transferred to Another Acute Care Facility
|
Facility
IP
|
$41,582.23
|
|
|
Service Code
|
MS-DRG 7897
|
| Hospital Charge Code |
679
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$41,582.23 |
| Rate for Payer: Amerigroup Medicaid |
$41,381.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$40,979.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$41,582.23
|
|
|
Level 3: Neonate W Other Significant Problems
|
Facility
IP
|
$3,267.68
|
|
|
Service Code
|
MS-DRG 7947
|
| Hospital Charge Code |
689
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$3,267.68 |
| Rate for Payer: Amerigroup Medicaid |
$3,251.90
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,220.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,267.68
|
|
|
Level 3: Normal Newborn
|
Facility
IP
|
$2,844.46
|
|
|
Service Code
|
MS-DRG 7957
|
| Hospital Charge Code |
691
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$2,844.46 |
| Rate for Payer: Amerigroup Medicaid |
$2,830.72
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,803.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,844.46
|
|
|
Level 3: Prematurity W Major Problems
|
Facility
IP
|
$37,116.74
|
|
|
Service Code
|
MS-DRG 7917
|
| Hospital Charge Code |
683
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$37,116.74 |
| Rate for Payer: Amerigroup Medicaid |
$36,937.43
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$36,578.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37,116.74
|
|
|
Level 3: Prematurity W/O Major Problems
|
Facility
IP
|
$12,759.71
|
|
|
Service Code
|
MS-DRG 7927
|
| Hospital Charge Code |
685
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$12,759.71 |
| Rate for Payer: Amerigroup Medicaid |
$12,698.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,034.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12,574.78
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12,759.71
|
|
|
LEVEL 4
|
Facility
OP
|
$711.00
|
|
|
Service Code
|
CPT 99284 25
|
| Hospital Charge Code |
6922788
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$355.36 |
| Max. Negotiated Rate |
$639.90 |
| Rate for Payer: Aetna of IA Commercial |
$639.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$639.90
|
| Rate for Payer: Aetna of IA Medicare |
$405.27
|
| Rate for Payer: Amerigroup Medicaid |
$358.84
|
| Rate for Payer: Amerigroup Medicare |
$359.06
|
| Rate for Payer: Cash Price |
$568.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$533.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$355.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$355.36
|
| Rate for Payer: Medical Associates Commercial |
$533.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$355.50
|
| Rate for Payer: Midlands Choice Commercial |
$497.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$360.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$533.25
|
| Rate for Payer: United Healthcare Commercial |
$639.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$419.49
|
|
|
LEVEL 4
|
Facility
IP
|
$711.00
|
|
|
Service Code
|
CPT 99284 25
|
| Hospital Charge Code |
6922788
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$497.70 |
| Max. Negotiated Rate |
$639.90 |
| Rate for Payer: Aetna of IA Commercial |
$639.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$639.90
|
| Rate for Payer: Cash Price |
$568.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$533.25
|
| Rate for Payer: Medical Associates Commercial |
$533.25
|
| Rate for Payer: Midlands Choice Commercial |
$497.70
|
| Rate for Payer: United Healthcare Commercial |
$639.90
|
|
|
LEVEL 4
|
Professional
|
$359.00
|
|
|
Service Code
|
CPT 99284
|
| Hospital Charge Code |
7982752
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$110.80 |
| Max. Negotiated Rate |
$251.30 |
| Rate for Payer: Aetna of IA Medicare |
$110.80
|
| Rate for Payer: Amerigroup Medicaid |
$114.57
|
| Rate for Payer: Cash Price |
$287.20
|
| Rate for Payer: Cash Price |
$287.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$113.02
|
| Rate for Payer: Medical Associates Commercial |
$210.52
|
| Rate for Payer: Medical Associates Managed Medicare |
$110.80
|
| Rate for Payer: Midlands Choice Commercial |
$251.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$166.20
|
| Rate for Payer: United Healthcare Commercial |
$129.49
|
| Rate for Payer: Wellmark IA HMO |
$188.00
|
| Rate for Payer: Wellmark IA PPO |
$188.00
|
|
|
LEVEL 5
|
Professional
|
$529.00
|
|
|
Service Code
|
CPT 99285
|
| Hospital Charge Code |
7982751
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$160.58 |
| Max. Negotiated Rate |
$370.30 |
| Rate for Payer: Aetna of IA Medicare |
$160.58
|
| Rate for Payer: Amerigroup Medicaid |
$166.04
|
| Rate for Payer: Cash Price |
$423.20
|
| Rate for Payer: Cash Price |
$423.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$192.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$163.79
|
| Rate for Payer: Medical Associates Commercial |
$305.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$160.58
|
| Rate for Payer: Midlands Choice Commercial |
$370.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$240.87
|
| Rate for Payer: United Healthcare Commercial |
$202.69
|
| Rate for Payer: Wellmark IA HMO |
$273.00
|
| Rate for Payer: Wellmark IA PPO |
$273.00
|
|
|
LEVEL 5
|
Facility
IP
|
$1,042.00
|
|
|
Service Code
|
CPT 99285 25
|
| Hospital Charge Code |
6922790
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$729.40 |
| Max. Negotiated Rate |
$937.80 |
| Rate for Payer: Aetna of IA Commercial |
$937.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$937.80
|
| Rate for Payer: Cash Price |
$833.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$781.50
|
| Rate for Payer: Medical Associates Commercial |
$781.50
|
| Rate for Payer: Midlands Choice Commercial |
$729.40
|
| Rate for Payer: United Healthcare Commercial |
$937.80
|
|
|
LEVEL 5
|
Facility
OP
|
$1,042.00
|
|
|
Service Code
|
CPT 99285 25
|
| Hospital Charge Code |
6922790
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$520.79 |
| Max. Negotiated Rate |
$937.80 |
| Rate for Payer: Aetna of IA Commercial |
$937.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$937.80
|
| Rate for Payer: Aetna of IA Medicare |
$593.94
|
| Rate for Payer: Amerigroup Medicaid |
$525.90
|
| Rate for Payer: Amerigroup Medicare |
$526.21
|
| Rate for Payer: Cash Price |
$833.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$781.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$521.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$520.79
|
| Rate for Payer: Medical Associates Commercial |
$781.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$521.00
|
| Rate for Payer: Midlands Choice Commercial |
$729.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$528.82
|
| Rate for Payer: Partners Health Alliance Commercial |
$781.50
|
| Rate for Payer: United Healthcare Commercial |
$937.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$614.78
|
|
|
levETIRAcetam 100 mg/mL 5ml cup Oral Sol
|
Facility
IP
|
$13.70
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43791477
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Aetna of IA Commercial |
$12.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.33
|
| Rate for Payer: Cash Price |
$10.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.28
|
| Rate for Payer: Medical Associates Commercial |
$10.28
|
| Rate for Payer: Midlands Choice Commercial |
$9.59
|
| Rate for Payer: United Healthcare Commercial |
$12.33
|
|
