|
Lipoprotein A DMCL
|
Facility
OP
|
$140.00
|
|
|
Service Code
|
CPT 83695
|
| Hospital Charge Code |
8632496
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna of IA Commercial |
$126.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$126.00
|
| Rate for Payer: Aetna of IA Medicare |
$79.80
|
| Rate for Payer: Amerigroup Medicaid |
$70.66
|
| Rate for Payer: Amerigroup Medicare |
$70.70
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$105.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$70.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.97
|
| Rate for Payer: Medical Associates Commercial |
$105.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$70.00
|
| Rate for Payer: Midlands Choice Commercial |
$98.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$71.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$105.00
|
| Rate for Payer: United Healthcare Commercial |
$126.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.60
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
liraglutide 18 mg/3 mL Sol
|
Facility
IP
|
$1,389.66
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$972.76 |
| Max. Negotiated Rate |
$1,250.69 |
| Rate for Payer: Aetna of IA Commercial |
$1,250.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,250.69
|
| Rate for Payer: Cash Price |
$1,111.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,042.24
|
| Rate for Payer: Medical Associates Commercial |
$1,042.24
|
| Rate for Payer: Midlands Choice Commercial |
$972.76
|
| Rate for Payer: United Healthcare Commercial |
$1,250.69
|
|
|
liraglutide 18 mg/3 mL Sol
|
Facility
OP
|
$1,389.66
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$694.55 |
| Max. Negotiated Rate |
$1,250.69 |
| Rate for Payer: Aetna of IA Commercial |
$1,250.69
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,250.69
|
| Rate for Payer: Aetna of IA Medicare |
$792.11
|
| Rate for Payer: Amerigroup Medicaid |
$701.36
|
| Rate for Payer: Amerigroup Medicare |
$701.78
|
| Rate for Payer: Cash Price |
$1,111.73
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,042.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$694.83
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$694.55
|
| Rate for Payer: Medical Associates Commercial |
$1,042.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$694.83
|
| Rate for Payer: Midlands Choice Commercial |
$972.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$705.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,042.24
|
| Rate for Payer: United Healthcare Commercial |
$1,250.69
|
| Rate for Payer: United Healthcare Managed Medicare |
$819.90
|
|
|
lisinopril 20 mg Tab
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
|
|
lisinopril 20 mg Tab
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Aetna of IA Medicare |
$0.72
|
| Rate for Payer: Amerigroup Medicaid |
$0.64
|
| Rate for Payer: Amerigroup Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.63
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.63
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
|
lisinopril 5 mg Tab
|
Facility
OP
|
$1.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of IA Commercial |
$1.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.05
|
| Rate for Payer: Aetna of IA Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicaid |
$0.59
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| 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 |
$0.58
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.69
|
|
|
lisinopril 5 mg Tab
|
Facility
IP
|
$1.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of IA Commercial |
$1.05
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.05
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.88
|
| Rate for Payer: Medical Associates Commercial |
$0.88
|
| Rate for Payer: Midlands Choice Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
|
|
lisinopril-HCTZ 20mg-25mg tab
|
Facility
OP
|
$1.14
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of IA Commercial |
$1.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.03
|
| Rate for Payer: Aetna of IA Medicare |
$0.65
|
| Rate for Payer: Amerigroup Medicaid |
$0.58
|
| Rate for Payer: Amerigroup Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.57
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.57
|
| Rate for Payer: Midlands Choice Commercial |
$0.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.67
|
|
|
lisinopril-HCTZ 20mg-25mg tab
|
Facility
IP
|
$1.14
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of IA Commercial |
$1.03
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.03
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.86
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Midlands Choice Commercial |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
|
|
lithium 150 mg Cap
|
Facility
OP
|
$1.30
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of IA Commercial |
$1.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.17
|
| Rate for Payer: Aetna of IA Medicare |
$0.74
|
| Rate for Payer: Amerigroup Medicaid |
$0.66
|
| Rate for Payer: Amerigroup Medicare |
$0.66
|
| 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 |
$0.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.65
|
| Rate for Payer: Medical Associates Commercial |
$0.98
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.65
|
| Rate for Payer: Midlands Choice Commercial |
$0.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.77
|
|
|
lithium 150 mg Cap
|
Facility
IP
|
$1.30
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of IA Commercial |
$1.17
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.17
|
| 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 |
$1.17
|
|
|
lithium 300 mg Cap
|
Facility
OP
|
$1.72
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Aetna of IA Commercial |
$1.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.55
|
| Rate for Payer: Aetna of IA Medicare |
$0.98
|
| Rate for Payer: Amerigroup Medicaid |
$0.87
|
| Rate for Payer: Amerigroup Medicare |
$0.87
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.29
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.86
|
| Rate for Payer: Medical Associates Commercial |
$1.29
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.86
|
| Rate for Payer: Midlands Choice Commercial |
$1.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.29
|
| Rate for Payer: United Healthcare Commercial |
$1.55
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.01
|
|
|
lithium 300 mg Cap
|
Facility
IP
|
$1.72
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Aetna of IA Commercial |
$1.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.55
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.29
|
| Rate for Payer: Medical Associates Commercial |
$1.29
|
| Rate for Payer: Midlands Choice Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.55
|
|
|
Lithium Level DMCL
|
Facility
OP
|
$63.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
8037727
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.49 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna of IA Commercial |
$56.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.70
|
| Rate for Payer: Aetna of IA Medicare |
$35.91
|
| Rate for Payer: Amerigroup Medicaid |
$31.80
|
| Rate for Payer: Amerigroup Medicare |
$31.82
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.49
|
| Rate for Payer: Medical Associates Commercial |
$47.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.50
|
| Rate for Payer: Midlands Choice Commercial |
$44.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.25
|
| Rate for Payer: United Healthcare Commercial |
$56.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.17
|
| Rate for Payer: Wellmark IA HMO |
$49.60
|
| Rate for Payer: Wellmark IA PPO |
$54.56
|
|
|
Lithium Level DMCL
|
Facility
IP
|
$63.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
8037727
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna of IA Commercial |
$56.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.70
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.25
|
| Rate for Payer: Medical Associates Commercial |
$47.25
|
| Rate for Payer: Midlands Choice Commercial |
$44.10
|
| Rate for Payer: United Healthcare Commercial |
$56.70
|
|
|
LITHOTRIPSY CHARGE
|
Facility
OP
|
$4,114.00
|
|
| Hospital Charge Code |
8069084
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,056.18 |
| Max. Negotiated Rate |
$3,702.60 |
| Rate for Payer: Aetna of IA Commercial |
$3,702.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,702.60
|
| Rate for Payer: Aetna of IA Medicare |
$2,344.98
|
| Rate for Payer: Amerigroup Medicaid |
$2,076.34
|
| Rate for Payer: Amerigroup Medicare |
$2,077.57
|
| Rate for Payer: Cash Price |
$3,291.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,085.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2,057.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2,056.18
|
| Rate for Payer: Medical Associates Commercial |
$3,085.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$2,057.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,879.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2,087.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$3,085.50
|
| Rate for Payer: United Healthcare Commercial |
$3,702.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,427.26
|
|
|
LITHOTRIPSY CHARGE
|
Facility
IP
|
$4,114.00
|
|
| Hospital Charge Code |
8069084
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,879.80 |
| Max. Negotiated Rate |
$3,702.60 |
| Rate for Payer: Aetna of IA Commercial |
$3,702.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,702.60
|
| Rate for Payer: Cash Price |
$3,291.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3,085.50
|
| Rate for Payer: Medical Associates Commercial |
$3,085.50
|
| Rate for Payer: Midlands Choice Commercial |
$2,879.80
|
| Rate for Payer: United Healthcare Commercial |
$3,702.60
|
|
|
LIVER PROFILE
|
Facility
OP
|
$111.00
|
|
|
Service Code
|
CPT 80076
|
| Hospital Charge Code |
633744
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Aetna of IA Medicare |
$63.27
|
| Rate for Payer: Amerigroup Medicaid |
$56.02
|
| Rate for Payer: Amerigroup Medicare |
$56.06
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.48
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.50
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.25
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.49
|
| Rate for Payer: Wellmark IA HMO |
$52.08
|
| Rate for Payer: Wellmark IA PPO |
$57.29
|
|
|
LIVER PROFILE
|
Facility
IP
|
$111.00
|
|
|
Service Code
|
CPT 80076
|
| Hospital Charge Code |
633744
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$99.90 |
| Rate for Payer: Aetna of IA Commercial |
$99.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$99.90
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.25
|
| Rate for Payer: Medical Associates Commercial |
$83.25
|
| Rate for Payer: Midlands Choice Commercial |
$77.70
|
| Rate for Payer: United Healthcare Commercial |
$99.90
|
|
|
Liver Transplant With MCC or Intestinal Transplant
|
Facility
IP
|
$158,834.93
|
|
|
Service Code
|
MS-DRG 005
|
| Hospital Charge Code |
696
|
| Min. Negotiated Rate |
$156,532.97 |
| Max. Negotiated Rate |
$158,834.93 |
| Rate for Payer: Amerigroup Medicaid |
$158,067.61
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$156,532.97
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$158,834.93
|
|
|
Liver Transplant Without MCC
|
Facility
IP
|
$89,346.49
|
|
|
Service Code
|
MS-DRG 006
|
| Hospital Charge Code |
697
|
| Min. Negotiated Rate |
$88,051.61 |
| Max. Negotiated Rate |
$89,346.49 |
| Rate for Payer: Amerigroup Medicaid |
$88,914.86
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$88,051.61
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$89,346.49
|
|
|
Local Excision and Removal of Internal Fixation Devices Except Hip and Femur With CC
|
Facility
IP
|
$17,486.04
|
|
|
Service Code
|
MS-DRG 496
|
| Hospital Charge Code |
313
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$17,486.04 |
| Rate for Payer: Amerigroup Medicaid |
$17,401.56
|
| 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 |
$17,232.61
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17,486.04
|
|
|
Local Excision and Removal of Internal Fixation Devices Except Hip and Femur With MCC
|
Facility
IP
|
$35,778.16
|
|
|
Service Code
|
MS-DRG 495
|
| Hospital Charge Code |
312
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$35,778.16 |
| Rate for Payer: Amerigroup Medicaid |
$35,605.32
|
| 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 |
$35,259.64
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$35,778.16
|
|
|
Local Excision and Removal of Internal Fixation Devices Except Hip and Femur Without CC/MCC
|
Facility
IP
|
$11,221.34
|
|
|
Service Code
|
MS-DRG 497
|
| Hospital Charge Code |
314
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$11,221.34 |
| Rate for Payer: Amerigroup Medicaid |
$11,167.13
|
| 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 |
$11,058.71
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11,221.34
|
|
|
Local Excision and Removal of Internal Fixation Devices of Hip and Femur With CC/MCC
|
Facility
IP
|
$25,442.64
|
|
|
Service Code
|
MS-DRG 498
|
| Hospital Charge Code |
315
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$25,442.64 |
| Rate for Payer: Amerigroup Medicaid |
$25,319.73
|
| 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 |
$25,073.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25,442.64
|
|
