|
activated charcoal-sorbitol 50 g Oral Susp 240 mL
|
Facility
IP
|
$78.48
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43762589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.94 |
| Max. Negotiated Rate |
$70.63 |
| Rate for Payer: Aetna of IA Commercial |
$70.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.63
|
| Rate for Payer: Cash Price |
$62.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.86
|
| Rate for Payer: Medical Associates Commercial |
$58.86
|
| Rate for Payer: Midlands Choice Commercial |
$54.94
|
| Rate for Payer: United Healthcare Commercial |
$70.63
|
|
|
activated charcoal-sorbitol 50 g Oral Susp 240 mL
|
Facility
OP
|
$78.48
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43762589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.22 |
| Max. Negotiated Rate |
$70.63 |
| Rate for Payer: Aetna of IA Commercial |
$70.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$70.63
|
| Rate for Payer: Aetna of IA Medicare |
$44.73
|
| Rate for Payer: Amerigroup Medicaid |
$39.61
|
| Rate for Payer: Amerigroup Medicare |
$39.63
|
| Rate for Payer: Cash Price |
$62.79
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$58.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$39.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$39.22
|
| Rate for Payer: Medical Associates Commercial |
$58.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$39.24
|
| Rate for Payer: Midlands Choice Commercial |
$54.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$39.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$58.86
|
| Rate for Payer: United Healthcare Commercial |
$70.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$46.30
|
|
|
Acute Adjustment Reaction and Psychosocial Dysfunction
|
Facility
IP
|
$5,345.41
|
|
|
Service Code
|
MS-DRG 880
|
| Hospital Charge Code |
610
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$5,345.41 |
| Rate for Payer: Amerigroup Medicaid |
$5,319.59
|
| 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 |
$5,267.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,345.41
|
|
|
Acute and Subacute Endocarditis With CC
|
Facility
IP
|
$14,157.33
|
|
|
Service Code
|
MS-DRG 289
|
| Hospital Charge Code |
146
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$14,157.33 |
| Rate for Payer: Amerigroup Medicaid |
$14,088.94
|
| 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 |
$13,952.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14,157.33
|
|
|
Acute and Subacute Endocarditis With MCC
|
Facility
IP
|
$18,667.13
|
|
|
Service Code
|
MS-DRG 288
|
| Hospital Charge Code |
145
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$18,667.13 |
| Rate for Payer: Amerigroup Medicaid |
$18,576.95
|
| 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 |
$18,396.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18,667.13
|
|
|
Acute and Subacute Endocarditis Without CC/MCC
|
Facility
IP
|
$10,077.65
|
|
|
Service Code
|
MS-DRG 290
|
| Hospital Charge Code |
147
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$10,077.65 |
| Rate for Payer: Amerigroup Medicaid |
$10,028.97
|
| 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 |
$9,931.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,077.65
|
|
|
ACUTE HEPATITIS PROFILE
|
Facility
OP
|
$303.00
|
|
|
Service Code
|
CPT 80074
|
| Hospital Charge Code |
8037485
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$272.70 |
| Rate for Payer: Aetna of IA Commercial |
$272.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$272.70
|
| Rate for Payer: Aetna of IA Medicare |
$172.71
|
| Rate for Payer: Amerigroup Medicaid |
$152.92
|
| Rate for Payer: Amerigroup Medicare |
$153.02
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$227.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$151.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$151.44
|
| Rate for Payer: Medical Associates Commercial |
$227.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$151.50
|
| Rate for Payer: Midlands Choice Commercial |
$212.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$153.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$227.25
|
| Rate for Payer: United Healthcare Commercial |
$272.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$178.77
|
| Rate for Payer: Wellmark IA HMO |
$52.08
|
| Rate for Payer: Wellmark IA PPO |
$57.29
|
|
|
ACUTE HEPATITIS PROFILE
|
Facility
IP
|
$303.00
|
|
|
Service Code
|
CPT 80074
|
| Hospital Charge Code |
8037485
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$212.10 |
| Max. Negotiated Rate |
$272.70 |
| Rate for Payer: Aetna of IA Commercial |
$272.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$272.70
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$227.25
|
| Rate for Payer: Medical Associates Commercial |
$227.25
|
| Rate for Payer: Midlands Choice Commercial |
$212.10
|
| Rate for Payer: United Healthcare Commercial |
$272.70
|
|
|
Acute Leukemia Without Major O.R. Procedures With CC
|
Facility
IP
|
$26,998.73
|
|
|
Service Code
|
MS-DRG 835
|
| Hospital Charge Code |
577
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$26,998.73 |
| Rate for Payer: Amerigroup Medicaid |
$26,868.30
|
| 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 |
$26,607.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26,998.73
|
|
|
Acute Leukemia Without Major O.R. Procedures With MCC
|
Facility
IP
|
$61,309.38
|
|
|
Service Code
|
MS-DRG 834
|
| Hospital Charge Code |
576
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$61,309.38 |
| Rate for Payer: Amerigroup Medicaid |
$61,013.20
|
| 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 |
$60,420.84
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$61,309.38
|
|
|
Acute Leukemia Without Major O.R. Procedures Without CC/MCC
|
Facility
IP
|
$11,514.64
|
|
|
Service Code
|
MS-DRG 836
|
| Hospital Charge Code |
578
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$11,514.64 |
| Rate for Payer: Amerigroup Medicaid |
$11,459.02
|
| 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 |
$11,347.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11,514.64
|
|
|
Acute Major Eye Infections With CC/MCC
|
Facility
IP
|
$8,091.45
|
|
|
Service Code
|
MS-DRG 121
|
| Hospital Charge Code |
10
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$8,091.45 |
| Rate for Payer: Amerigroup Medicaid |
$8,052.36
|
| 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 |
$7,974.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,091.45
|
|
|
Acute Major Eye Infections Without CC/MCC
|
Facility
IP
|
$5,227.31
|
|
|
Service Code
|
MS-DRG 122
|
| Hospital Charge Code |
11
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$5,227.31 |
| Rate for Payer: Amerigroup Medicaid |
$5,202.06
|
| 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 |
$5,151.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,227.31
|
|
|
Acute Myocardial Infarction, Discharged Alive With CC
|
Facility
IP
|
$7,557.99
|
|
|
Service Code
|
MS-DRG 281
|
| Hospital Charge Code |
138
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,557.99 |
| Rate for Payer: Amerigroup Medicaid |
$7,521.48
|
| 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 |
$7,448.46
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,557.99
|
|
|
Acute Myocardial Infarction, Discharged Alive With MCC
|
Facility
IP
|
$13,101.24
|
|
|
Service Code
|
MS-DRG 280
|
| Hospital Charge Code |
137
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$13,101.24 |
| Rate for Payer: Amerigroup Medicaid |
$13,037.95
|
| 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 |
$12,911.36
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13,101.24
|
|
|
Acute Myocardial Infarction, Discharged Alive Without CC/MCC
|
Facility
IP
|
$6,237.14
|
|
|
Service Code
|
MS-DRG 282
|
| Hospital Charge Code |
139
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$6,237.14 |
| Rate for Payer: Amerigroup Medicaid |
$6,207.01
|
| 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 |
$6,146.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,237.14
|
|
|
Acute Myocardial Infarction, Expired With CC
|
Facility
IP
|
$7,226.30
|
|
|
Service Code
|
MS-DRG 284
|
| Hospital Charge Code |
141
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,226.30 |
| Rate for Payer: Amerigroup Medicaid |
$7,191.39
|
| 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 |
$7,121.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,226.30
|
|
|
Acute Myocardial Infarction, Expired With MCC
|
Facility
IP
|
$10,892.60
|
|
|
Service Code
|
MS-DRG 283
|
| Hospital Charge Code |
140
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$10,892.60 |
| Rate for Payer: Amerigroup Medicaid |
$10,839.98
|
| 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 |
$10,734.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,892.60
|
|
|
Acute Myocardial Infarction, Expired Without CC/MCC
|
Facility
IP
|
$4,885.78
|
|
|
Service Code
|
MS-DRG 285
|
| Hospital Charge Code |
142
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$4,885.78 |
| Rate for Payer: Amerigroup Medicaid |
$4,862.18
|
| 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 |
$4,814.97
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,885.78
|
|
|
acyclovir 400 mg Tab
|
Facility
OP
|
$1.24
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705931
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Aetna of IA Medicare |
$0.71
|
| Rate for Payer: Amerigroup Medicaid |
$0.63
|
| Rate for Payer: Amerigroup Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.93
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.62
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.62
|
| Rate for Payer: Medical Associates Commercial |
$0.93
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.62
|
| Rate for Payer: Midlands Choice Commercial |
$0.87
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.73
|
|
|
acyclovir 400 mg Tab
|
Facility
IP
|
$1.24
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705931
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.93
|
| Rate for Payer: Medical Associates Commercial |
$0.93
|
| Rate for Payer: Midlands Choice Commercial |
$0.87
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
|
|
acyclovir 50 mg/mL IV Sol 20 ml SDV
|
Facility
OP
|
$36.47
|
|
|
Service Code
|
CPT J0133
|
| Hospital Charge Code |
43703111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.23 |
| Max. Negotiated Rate |
$32.82 |
| Rate for Payer: Aetna of IA Commercial |
$32.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.82
|
| Rate for Payer: Aetna of IA Medicare |
$20.79
|
| Rate for Payer: Amerigroup Medicaid |
$18.41
|
| Rate for Payer: Amerigroup Medicare |
$18.42
|
| Rate for Payer: Cash Price |
$29.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$27.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$18.24
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$18.23
|
| Rate for Payer: Medical Associates Commercial |
$27.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$18.24
|
| Rate for Payer: Midlands Choice Commercial |
$25.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$18.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$27.35
|
| Rate for Payer: United Healthcare Commercial |
$32.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$21.52
|
|
|
acyclovir 50 mg/mL IV Sol 20 ml SDV
|
Facility
IP
|
$36.47
|
|
|
Service Code
|
CPT J0133
|
| Hospital Charge Code |
43703111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.53 |
| Max. Negotiated Rate |
$32.82 |
| Rate for Payer: Aetna of IA Commercial |
$32.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$32.82
|
| Rate for Payer: Cash Price |
$29.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$27.35
|
| Rate for Payer: Medical Associates Commercial |
$27.35
|
| Rate for Payer: Midlands Choice Commercial |
$25.53
|
| Rate for Payer: United Healthcare Commercial |
$32.82
|
|
|
acyclovir Top 5% Oint 15 gm
|
Facility
OP
|
$99.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701742
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.54 |
| Max. Negotiated Rate |
$89.21 |
| Rate for Payer: Aetna of IA Commercial |
$89.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$89.21
|
| Rate for Payer: Aetna of IA Medicare |
$56.50
|
| Rate for Payer: Amerigroup Medicaid |
$50.03
|
| Rate for Payer: Amerigroup Medicare |
$50.06
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$49.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$49.54
|
| Rate for Payer: Medical Associates Commercial |
$74.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$49.56
|
| Rate for Payer: Midlands Choice Commercial |
$69.38
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$50.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$74.34
|
| Rate for Payer: United Healthcare Commercial |
$89.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$58.48
|
|
|
acyclovir Top 5% Oint 15 gm
|
Facility
IP
|
$99.12
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701742
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.38 |
| Max. Negotiated Rate |
$89.21 |
| Rate for Payer: Aetna of IA Commercial |
$89.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$89.21
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$74.34
|
| Rate for Payer: Medical Associates Commercial |
$74.34
|
| Rate for Payer: Midlands Choice Commercial |
$69.38
|
| Rate for Payer: United Healthcare Commercial |
$89.21
|
|
