|
albuterol CFC free 90 mcg/inh Inh Aer w/Adapt
|
Facility
IP
|
$72.85
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna of IA Commercial |
$65.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$65.56
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.64
|
| Rate for Payer: Medical Associates Commercial |
$54.64
|
| Rate for Payer: Midlands Choice Commercial |
$51.00
|
| Rate for Payer: United Healthcare Commercial |
$65.56
|
|
|
albuterol-ipratropium 0.5mg/3mg neb Sol 3 mL SDV
|
Facility
IP
|
$4.97
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43714893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna of IA Commercial |
$4.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.47
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.73
|
| Rate for Payer: Medical Associates Commercial |
$3.73
|
| Rate for Payer: Midlands Choice Commercial |
$3.48
|
| Rate for Payer: United Healthcare Commercial |
$4.47
|
|
|
albuterol-ipratropium 0.5mg/3mg neb Sol 3 mL SDV
|
Facility
OP
|
$4.97
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43714893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna of IA Commercial |
$4.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$4.47
|
| Rate for Payer: Aetna of IA Medicare |
$2.83
|
| Rate for Payer: Amerigroup Medicaid |
$2.51
|
| Rate for Payer: Amerigroup Medicare |
$2.51
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.73
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.48
|
| Rate for Payer: Medical Associates Commercial |
$3.73
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.48
|
| Rate for Payer: Midlands Choice Commercial |
$3.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.73
|
| Rate for Payer: United Healthcare Commercial |
$4.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.93
|
|
|
albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aer
|
Facility
IP
|
$1,540.36
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,078.25 |
| Max. Negotiated Rate |
$1,386.32 |
| Rate for Payer: Aetna of IA Commercial |
$1,386.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,386.32
|
| Rate for Payer: Cash Price |
$1,232.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,155.27
|
| Rate for Payer: Medical Associates Commercial |
$1,155.27
|
| Rate for Payer: Midlands Choice Commercial |
$1,078.25
|
| Rate for Payer: United Healthcare Commercial |
$1,386.32
|
|
|
albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aer
|
Facility
OP
|
$1,540.36
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$769.87 |
| Max. Negotiated Rate |
$1,386.32 |
| Rate for Payer: Aetna of IA Commercial |
$1,386.32
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,386.32
|
| Rate for Payer: Aetna of IA Medicare |
$878.01
|
| Rate for Payer: Amerigroup Medicaid |
$777.42
|
| Rate for Payer: Amerigroup Medicare |
$777.88
|
| Rate for Payer: Cash Price |
$1,232.29
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,155.27
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$770.18
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$769.87
|
| Rate for Payer: Medical Associates Commercial |
$1,155.27
|
| Rate for Payer: Medical Associates Managed Medicare |
$770.18
|
| Rate for Payer: Midlands Choice Commercial |
$1,078.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$781.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,155.27
|
| Rate for Payer: United Healthcare Commercial |
$1,386.32
|
| Rate for Payer: United Healthcare Managed Medicare |
$908.81
|
|
|
ALCOHOL
|
Facility
OP
|
$139.00
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
1503765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$69.47 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Aetna of IA Medicare |
$79.23
|
| Rate for Payer: Amerigroup Medicaid |
$70.15
|
| Rate for Payer: Amerigroup Medicare |
$70.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$69.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.47
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$69.50
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$104.25
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.01
|
| Rate for Payer: Wellmark IA HMO |
$102.92
|
| Rate for Payer: Wellmark IA PPO |
$113.21
|
|
|
ALCOHOL
|
Facility
IP
|
$139.00
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
1503765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
|
|
Alcohol, Drug Abuse or Dependence, Left AMA
|
Facility
IP
|
$4,499.95
|
|
|
Service Code
|
MS-DRG 894
|
| Hospital Charge Code |
618
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$4,499.95 |
| Rate for Payer: Amerigroup Medicaid |
$4,478.21
|
| 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 |
$4,434.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4,499.95
|
|
|
Alcohol, Drug Abuse or Dependence Without Rehabilitation Therapy With MCC
|
Facility
IP
|
$12,018.58
|
|
|
Service Code
|
MS-DRG 896
|
| Hospital Charge Code |
620
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$12,018.58 |
| Rate for Payer: Amerigroup Medicaid |
$11,960.51
|
| 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 |
$11,844.39
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12,018.58
|
|
|
Alcohol, Drug Abuse or Dependence Without Rehabilitation Therapy Without MCC
|
Facility
IP
|
$6,877.88
|
|
|
Service Code
|
MS-DRG 897
|
| Hospital Charge Code |
621
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$6,877.88 |
| Rate for Payer: Amerigroup Medicaid |
$6,844.65
|
| 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 |
$6,778.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,877.88
|
|
|
Alcohol, Drug Abuse or Dependence With Rehabilitation Therapy
|
Facility
IP
|
$9,940.84
|
|
|
Service Code
|
MS-DRG 895
|
| Hospital Charge Code |
619
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$9,940.84 |
| Rate for Payer: Amerigroup Medicaid |
$9,892.82
|
| 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 |
$9,796.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9,940.84
|
|
|
ALDL
|
Facility
OP
|
$73.00
|
|
|
Service Code
|
CPT 83721
|
| Hospital Charge Code |
6310783
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$65.70 |
| Rate for Payer: Aetna of IA Commercial |
$65.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$65.70
|
| Rate for Payer: Aetna of IA Medicare |
$41.61
|
| Rate for Payer: Amerigroup Medicaid |
$36.84
|
| Rate for Payer: Amerigroup Medicare |
$36.86
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$36.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$36.49
|
| Rate for Payer: Medical Associates Commercial |
$54.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$36.50
|
| Rate for Payer: Midlands Choice Commercial |
$51.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$37.05
|
| Rate for Payer: Partners Health Alliance Commercial |
$54.75
|
| Rate for Payer: United Healthcare Commercial |
$65.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$43.07
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
ALDL
|
Facility
IP
|
$73.00
|
|
|
Service Code
|
CPT 83721
|
| Hospital Charge Code |
6310783
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$51.10 |
| Max. Negotiated Rate |
$65.70 |
| Rate for Payer: Aetna of IA Commercial |
$65.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$65.70
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$54.75
|
| Rate for Payer: Medical Associates Commercial |
$54.75
|
| Rate for Payer: Midlands Choice Commercial |
$51.10
|
| Rate for Payer: United Healthcare Commercial |
$65.70
|
|
|
ALDOLASE
|
Facility
IP
|
$66.00
|
|
|
Service Code
|
CPT 82085
|
| Hospital Charge Code |
8037487
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Aetna of IA Commercial |
$59.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.40
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.50
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
|
|
ALDOLASE
|
Facility
OP
|
$66.00
|
|
|
Service Code
|
CPT 82085
|
| Hospital Charge Code |
8037487
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.99 |
| Max. Negotiated Rate |
$59.40 |
| Rate for Payer: Aetna of IA Commercial |
$59.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$59.40
|
| Rate for Payer: Aetna of IA Medicare |
$37.62
|
| Rate for Payer: Amerigroup Medicaid |
$33.31
|
| Rate for Payer: Amerigroup Medicare |
$33.33
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$49.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$33.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$32.99
|
| Rate for Payer: Medical Associates Commercial |
$49.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$33.00
|
| Rate for Payer: Midlands Choice Commercial |
$46.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$33.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Commercial |
$59.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$38.94
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
|
ALDOSTERONE
|
Facility
OP
|
$277.00
|
|
|
Service Code
|
CPT 82088
|
| Hospital Charge Code |
8037488
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$85.56 |
| Max. Negotiated Rate |
$249.30 |
| Rate for Payer: Aetna of IA Commercial |
$249.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$249.30
|
| Rate for Payer: Aetna of IA Medicare |
$157.89
|
| Rate for Payer: Amerigroup Medicaid |
$139.80
|
| Rate for Payer: Amerigroup Medicare |
$139.88
|
| Rate for Payer: Cash Price |
$221.60
|
| Rate for Payer: Cash Price |
$221.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$207.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$138.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$138.44
|
| Rate for Payer: Medical Associates Commercial |
$207.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$138.50
|
| Rate for Payer: Midlands Choice Commercial |
$193.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$140.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$207.75
|
| Rate for Payer: United Healthcare Commercial |
$249.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$163.43
|
| Rate for Payer: Wellmark IA HMO |
$85.56
|
| Rate for Payer: Wellmark IA PPO |
$94.12
|
|
|
ALDOSTERONE
|
Facility
IP
|
$277.00
|
|
|
Service Code
|
CPT 82088
|
| Hospital Charge Code |
8037488
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$193.90 |
| Max. Negotiated Rate |
$249.30 |
| Rate for Payer: Aetna of IA Commercial |
$249.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$249.30
|
| Rate for Payer: Cash Price |
$221.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$207.75
|
| Rate for Payer: Medical Associates Commercial |
$207.75
|
| Rate for Payer: Midlands Choice Commercial |
$193.90
|
| Rate for Payer: United Healthcare Commercial |
$249.30
|
|
|
al hydroxide/mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL
|
Facility
IP
|
$12.36
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$11.12 |
| Rate for Payer: Aetna of IA Commercial |
$11.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.12
|
| Rate for Payer: Cash Price |
$9.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.27
|
| Rate for Payer: Medical Associates Commercial |
$9.27
|
| Rate for Payer: Midlands Choice Commercial |
$8.65
|
| Rate for Payer: United Healthcare Commercial |
$11.12
|
|
|
al hydroxide/mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL
|
Facility
OP
|
$12.36
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.18 |
| Max. Negotiated Rate |
$11.12 |
| Rate for Payer: Aetna of IA Commercial |
$11.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$11.12
|
| Rate for Payer: Aetna of IA Medicare |
$7.05
|
| Rate for Payer: Amerigroup Medicaid |
$6.24
|
| Rate for Payer: Amerigroup Medicare |
$6.24
|
| Rate for Payer: Cash Price |
$9.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.27
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.18
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.18
|
| Rate for Payer: Medical Associates Commercial |
$9.27
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.18
|
| Rate for Payer: Midlands Choice Commercial |
$8.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.27
|
| Rate for Payer: Partners Health Alliance Commercial |
$9.27
|
| Rate for Payer: United Healthcare Commercial |
$11.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$7.29
|
|
|
ALK PHOSPHATASE
|
Facility
IP
|
$53.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
1620878
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$47.70 |
| Rate for Payer: Aetna of IA Commercial |
$47.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.70
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.75
|
| Rate for Payer: Medical Associates Commercial |
$39.75
|
| Rate for Payer: Midlands Choice Commercial |
$37.10
|
| Rate for Payer: United Healthcare Commercial |
$47.70
|
|
|
ALK PHOSPHATASE
|
Facility
OP
|
$53.00
|
|
|
Service Code
|
CPT 84075
|
| Hospital Charge Code |
1620878
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$47.70 |
| Rate for Payer: Aetna of IA Commercial |
$47.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.70
|
| Rate for Payer: Aetna of IA Medicare |
$30.21
|
| Rate for Payer: Amerigroup Medicaid |
$26.75
|
| Rate for Payer: Amerigroup Medicare |
$26.76
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.49
|
| Rate for Payer: Medical Associates Commercial |
$39.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.50
|
| Rate for Payer: Midlands Choice Commercial |
$37.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.75
|
| Rate for Payer: United Healthcare Commercial |
$47.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.27
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
Allergic Reactions With MCC
|
Facility
IP
|
$11,120.94
|
|
|
Service Code
|
MS-DRG 915
|
| Hospital Charge Code |
633
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$11,120.94 |
| Rate for Payer: Amerigroup Medicaid |
$11,067.22
|
| 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 |
$10,959.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11,120.94
|
|
|
Allergic Reactions Without MCC
|
Facility
IP
|
$5,287.35
|
|
|
Service Code
|
MS-DRG 916
|
| Hospital Charge Code |
634
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$5,287.35 |
| Rate for Payer: Amerigroup Medicaid |
$5,261.81
|
| 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 |
$5,210.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,287.35
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
IP
|
$137,857.79
|
|
|
Service Code
|
MS-DRG 014
|
| Hospital Charge Code |
704
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$137,857.79 |
| Rate for Payer: Amerigroup Medicaid |
$137,191.81
|
| 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 |
$135,859.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$137,857.79
|
|
|
ALLOGRAFT 30X40MM 722-TS
|
Facility
IP
|
$3,960.00
|
|
|
Service Code
|
CPT L8699
|
| Hospital Charge Code |
8942325
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,772.00 |
| Max. Negotiated Rate |
$3,564.00 |
| Rate for Payer: Aetna of IA Commercial |
$3,564.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,564.00
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,970.00
|
| Rate for Payer: Medical Associates Commercial |
$2,970.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,772.00
|
| Rate for Payer: United Healthcare Commercial |
$3,564.00
|
|
