|
OT Cog Ther Intervent,First 15 Min Units
|
Facility
IP
|
$85.00
|
|
|
Service Code
|
CPT 97129
|
| Hospital Charge Code |
8774208
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$76.50 |
| Rate for Payer: Aetna of IA Commercial |
$76.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.50
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.75
|
| Rate for Payer: Medical Associates Commercial |
$63.75
|
| Rate for Payer: Midlands Choice Commercial |
$59.50
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
|
|
OT Cog Ther Intervent,First 15 Min Units
|
Facility
OP
|
$85.00
|
|
|
Service Code
|
CPT 97129
|
| Hospital Charge Code |
8774208
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$42.48 |
| Max. Negotiated Rate |
$122.08 |
| Rate for Payer: Aetna of IA Commercial |
$76.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.50
|
| Rate for Payer: Aetna of IA Medicare |
$48.45
|
| Rate for Payer: Amerigroup Medicaid |
$42.90
|
| Rate for Payer: Amerigroup Medicare |
$42.92
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$42.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$42.48
|
| Rate for Payer: Medical Associates Commercial |
$63.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$42.50
|
| Rate for Payer: Midlands Choice Commercial |
$59.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$43.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$76.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$50.15
|
| Rate for Payer: Wellmark IA HMO |
$110.98
|
| Rate for Payer: Wellmark IA PPO |
$122.08
|
|
|
OT EVAL
|
Facility
IP
|
$158.00
|
|
| Hospital Charge Code |
4812784
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
|
|
OT EVAL
|
Facility
OP
|
$158.00
|
|
| Hospital Charge Code |
4812784
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$78.97 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Aetna of IA Medicare |
$90.06
|
| Rate for Payer: Amerigroup Medicaid |
$79.74
|
| Rate for Payer: Amerigroup Medicare |
$79.79
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$78.97
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.00
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$80.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$118.50
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$93.22
|
|
|
OT EVAL HIGH COMPLEX 60 MIN
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
8397275
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$78.97 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Aetna of IA Medicare |
$90.06
|
| Rate for Payer: Amerigroup Medicaid |
$79.74
|
| Rate for Payer: Amerigroup Medicare |
$79.79
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$78.97
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.00
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$80.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$118.50
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$93.22
|
|
|
OT EVAL HIGH COMPLEX 60 MIN
|
Facility
IP
|
$158.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
8397275
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
|
|
OT EVAL LOW COMPLEX 30 MIN
|
Facility
IP
|
$158.00
|
|
|
Service Code
|
CPT 97165 GO
|
| Hospital Charge Code |
8397258
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
|
|
OT EVAL LOW COMPLEX 30 MIN
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT 97165 GO
|
| Hospital Charge Code |
8397258
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$78.97 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Aetna of IA Medicare |
$90.06
|
| Rate for Payer: Amerigroup Medicaid |
$79.74
|
| Rate for Payer: Amerigroup Medicare |
$79.79
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$78.97
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.00
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$80.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$118.50
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$93.22
|
|
|
OT EVAL MOD COMPLEX 45 MIN
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
8397267
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$78.97 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Aetna of IA Medicare |
$90.06
|
| Rate for Payer: Amerigroup Medicaid |
$79.74
|
| Rate for Payer: Amerigroup Medicare |
$79.79
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$78.97
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.00
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$80.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$118.50
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$93.22
|
|
|
OT EVAL MOD COMPLEX 45 MIN
|
Facility
IP
|
$158.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
8397267
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of IA Commercial |
$142.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$142.20
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$118.50
|
| Rate for Payer: Medical Associates Commercial |
$118.50
|
| Rate for Payer: Midlands Choice Commercial |
$110.60
|
| Rate for Payer: United Healthcare Commercial |
$142.20
|
|
|
Other Antepartum Diagnoses With O.R. Procedures With CC
|
Facility
IP
|
$7,885.75
|
|
|
Service Code
|
MS-DRG 818
|
| Hospital Charge Code |
560
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,885.75 |
| Rate for Payer: Amerigroup Medicaid |
$7,847.65
|
| 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 |
$7,771.46
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,885.75
|
|
|
Other Antepartum Diagnoses With O.R. Procedures With MCC
|
Facility
IP
|
$10,904.41
|
|
|
Service Code
|
MS-DRG 817
|
| Hospital Charge Code |
559
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$10,904.41 |
| Rate for Payer: Amerigroup Medicaid |
$10,851.73
|
| 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 |
$10,746.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,904.41
|
|
|
Other Antepartum Diagnoses With O.R. Procedures Without CC/MCC
|
Facility
IP
|
$7,015.68
|
|
|
Service Code
|
MS-DRG 819
|
| Hospital Charge Code |
561
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,015.68 |
| Rate for Payer: Amerigroup Medicaid |
$6,981.78
|
| 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 |
$6,914.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,015.68
|
|
|
Other Antepartum Diagnoses Without O.R. Procedures With CC
|
Facility
IP
|
$5,121.00
|
|
|
Service Code
|
MS-DRG 832
|
| Hospital Charge Code |
574
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$5,121.00 |
| Rate for Payer: Amerigroup Medicaid |
$5,096.26
|
| 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 |
$5,046.79
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,121.00
|
|
|
Other Antepartum Diagnoses Without O.R. Procedures With MCC
|
Facility
IP
|
$6,979.25
|
|
|
Service Code
|
MS-DRG 831
|
| Hospital Charge Code |
573
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$6,979.25 |
| Rate for Payer: Amerigroup Medicaid |
$6,945.54
|
| 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 |
$6,878.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,979.25
|
|
|
Other Antepartum Diagnoses Without O.R. Procedures Without CC/MCC
|
Facility
IP
|
$3,925.15
|
|
|
Service Code
|
MS-DRG 833
|
| Hospital Charge Code |
575
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$3,925.15 |
| Rate for Payer: Amerigroup Medicaid |
$3,906.19
|
| 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 |
$3,868.27
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,925.15
|
|
|
Other Cardiothoracic Procedures With MCC
|
Facility
IP
|
$52,023.07
|
|
|
Service Code
|
MS-DRG 228
|
| Hospital Charge Code |
93
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$52,023.07 |
| Rate for Payer: Amerigroup Medicaid |
$51,771.76
|
| 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 |
$51,269.12
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$52,023.07
|
|
|
Other Cardiothoracic Procedures Without MCC
|
Facility
IP
|
$30,339.24
|
|
|
Service Code
|
MS-DRG 229
|
| Hospital Charge Code |
94
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$30,339.24 |
| Rate for Payer: Amerigroup Medicaid |
$30,192.68
|
| 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 |
$29,899.55
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30,339.24
|
|
|
Other Circulatory System Diagnoses With CC
|
Facility
IP
|
$9,138.69
|
|
|
Service Code
|
MS-DRG 315
|
| Hospital Charge Code |
172
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$9,138.69 |
| Rate for Payer: Amerigroup Medicaid |
$9,094.54
|
| 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 |
$9,006.24
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9,138.69
|
|
|
Other Circulatory System Diagnoses With MCC
|
Facility
IP
|
$17,263.59
|
|
|
Service Code
|
MS-DRG 314
|
| Hospital Charge Code |
171
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$17,263.59 |
| Rate for Payer: Amerigroup Medicaid |
$17,180.19
|
| 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 |
$17,013.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17,263.59
|
|
|
Other Circulatory System Diagnoses Without CC/MCC
|
Facility
IP
|
$5,521.59
|
|
|
Service Code
|
MS-DRG 316
|
| Hospital Charge Code |
173
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$5,521.59 |
| Rate for Payer: Amerigroup Medicaid |
$5,494.92
|
| 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 |
$5,441.57
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,521.59
|
|
|
Other Circulatory System O.R. Procedures
|
Facility
IP
|
$24,007.62
|
|
|
Service Code
|
MS-DRG 264
|
| Hospital Charge Code |
126
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$24,007.62 |
| Rate for Payer: Amerigroup Medicaid |
$23,891.64
|
| 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 |
$23,659.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24,007.62
|
|
|
Other Digestive System Diagnoses With CC
|
Facility
IP
|
$7,475.32
|
|
|
Service Code
|
MS-DRG 394
|
| Hospital Charge Code |
235
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,475.32 |
| Rate for Payer: Amerigroup Medicaid |
$7,439.21
|
| 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 |
$7,366.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,475.32
|
|
|
Other Digestive System Diagnoses With MCC
|
Facility
IP
|
$14,346.30
|
|
|
Service Code
|
MS-DRG 393
|
| Hospital Charge Code |
234
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$14,346.30 |
| Rate for Payer: Amerigroup Medicaid |
$14,276.99
|
| 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 |
$14,138.38
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14,346.30
|
|
|
Other Digestive System Diagnoses Without CC/MCC
|
Facility
IP
|
$6,923.16
|
|
|
Service Code
|
MS-DRG 395
|
| Hospital Charge Code |
236
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$6,923.16 |
| Rate for Payer: Amerigroup Medicaid |
$6,889.71
|
| 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 |
$6,822.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,923.16
|
|
