|
amoxicillin-clavulanate 875 mg-125 mg Tab
|
Facility
IP
|
$2.73
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna of IA Commercial |
$2.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.46
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.05
|
| Rate for Payer: Medical Associates Commercial |
$2.05
|
| Rate for Payer: Midlands Choice Commercial |
$1.91
|
| Rate for Payer: United Healthcare Commercial |
$2.46
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab
|
Facility
OP
|
$2.73
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna of IA Commercial |
$2.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2.46
|
| Rate for Payer: Aetna of IA Medicare |
$1.56
|
| Rate for Payer: Amerigroup Medicaid |
$1.38
|
| Rate for Payer: Amerigroup Medicare |
$1.38
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.05
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.36
|
| Rate for Payer: Medical Associates Commercial |
$2.05
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.36
|
| Rate for Payer: Midlands Choice Commercial |
$1.91
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.05
|
| Rate for Payer: United Healthcare Commercial |
$2.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.61
|
|
|
amphotericin B 50 mg soln SDV
|
Facility
IP
|
$152.76
|
|
|
Service Code
|
CPT J0285
|
| Hospital Charge Code |
43705794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.93 |
| Max. Negotiated Rate |
$137.48 |
| Rate for Payer: Aetna of IA Commercial |
$137.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$137.48
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.57
|
| Rate for Payer: Medical Associates Commercial |
$114.57
|
| Rate for Payer: Midlands Choice Commercial |
$106.93
|
| Rate for Payer: United Healthcare Commercial |
$137.48
|
|
|
amphotericin B 50 mg soln SDV
|
Facility
OP
|
$152.76
|
|
|
Service Code
|
CPT J0285
|
| Hospital Charge Code |
43705794
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.35 |
| Max. Negotiated Rate |
$137.48 |
| Rate for Payer: Aetna of IA Commercial |
$137.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$137.48
|
| Rate for Payer: Aetna of IA Medicare |
$87.07
|
| Rate for Payer: Amerigroup Medicaid |
$77.10
|
| Rate for Payer: Amerigroup Medicare |
$77.14
|
| Rate for Payer: Cash Price |
$122.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$114.57
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$76.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$76.35
|
| Rate for Payer: Medical Associates Commercial |
$114.57
|
| Rate for Payer: Medical Associates Managed Medicare |
$76.38
|
| Rate for Payer: Midlands Choice Commercial |
$106.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$77.53
|
| Rate for Payer: Partners Health Alliance Commercial |
$114.57
|
| Rate for Payer: United Healthcare Commercial |
$137.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$90.13
|
|
|
amphotericin B liposomal 50 mg IV Inj SDV
|
Facility
OP
|
$289.84
|
|
|
Service Code
|
CPT J0289
|
| Hospital Charge Code |
43700341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.86 |
| Max. Negotiated Rate |
$260.86 |
| Rate for Payer: Aetna of IA Commercial |
$260.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$260.86
|
| Rate for Payer: Aetna of IA Medicare |
$165.21
|
| Rate for Payer: Amerigroup Medicaid |
$146.28
|
| Rate for Payer: Amerigroup Medicare |
$146.37
|
| Rate for Payer: Cash Price |
$231.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$217.38
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$144.92
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$144.86
|
| Rate for Payer: Medical Associates Commercial |
$217.38
|
| Rate for Payer: Medical Associates Managed Medicare |
$144.92
|
| Rate for Payer: Midlands Choice Commercial |
$202.89
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$147.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$217.38
|
| Rate for Payer: United Healthcare Commercial |
$260.86
|
| Rate for Payer: United Healthcare Managed Medicare |
$171.01
|
|
|
amphotericin B liposomal 50 mg IV Inj SDV
|
Facility
IP
|
$289.84
|
|
|
Service Code
|
CPT J0289
|
| Hospital Charge Code |
43700341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.89 |
| Max. Negotiated Rate |
$260.86 |
| Rate for Payer: Aetna of IA Commercial |
$260.86
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$260.86
|
| Rate for Payer: Cash Price |
$231.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$217.38
|
| Rate for Payer: Medical Associates Commercial |
$217.38
|
| Rate for Payer: Midlands Choice Commercial |
$202.89
|
| Rate for Payer: United Healthcare Commercial |
$260.86
|
|
|
ampicillin 1 g Inj SDV
|
Facility
OP
|
$24.81
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
43701224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$22.33 |
| Rate for Payer: Aetna of IA Commercial |
$22.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.33
|
| Rate for Payer: Aetna of IA Medicare |
$14.14
|
| Rate for Payer: Amerigroup Medicaid |
$12.52
|
| Rate for Payer: Amerigroup Medicare |
$12.53
|
| Rate for Payer: Cash Price |
$19.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.61
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.40
|
| Rate for Payer: Medical Associates Commercial |
$18.61
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.40
|
| Rate for Payer: Midlands Choice Commercial |
$17.37
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.59
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.61
|
| Rate for Payer: United Healthcare Commercial |
$22.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.64
|
|
|
ampicillin 1 g Inj SDV
|
Facility
IP
|
$24.81
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
43701224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.37 |
| Max. Negotiated Rate |
$22.33 |
| Rate for Payer: Aetna of IA Commercial |
$22.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.33
|
| Rate for Payer: Cash Price |
$19.85
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.61
|
| Rate for Payer: Medical Associates Commercial |
$18.61
|
| Rate for Payer: Midlands Choice Commercial |
$17.37
|
| Rate for Payer: United Healthcare Commercial |
$22.33
|
|
|
ampicillin 2 g Inj SDV
|
Facility
OP
|
$28.08
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
43701226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.03 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Aetna of IA Commercial |
$25.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.27
|
| Rate for Payer: Aetna of IA Medicare |
$16.01
|
| Rate for Payer: Amerigroup Medicaid |
$14.17
|
| Rate for Payer: Amerigroup Medicare |
$14.18
|
| Rate for Payer: Cash Price |
$22.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.06
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.03
|
| Rate for Payer: Medical Associates Commercial |
$21.06
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.04
|
| Rate for Payer: Midlands Choice Commercial |
$19.66
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.06
|
| Rate for Payer: United Healthcare Commercial |
$25.27
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.57
|
|
|
ampicillin 2 g Inj SDV
|
Facility
IP
|
$28.08
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
43701226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Aetna of IA Commercial |
$25.27
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.27
|
| Rate for Payer: Cash Price |
$22.47
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.06
|
| Rate for Payer: Medical Associates Commercial |
$21.06
|
| Rate for Payer: Midlands Choice Commercial |
$19.66
|
| Rate for Payer: United Healthcare Commercial |
$25.27
|
|
|
ampicillin 500 mg Inj SDV
|
Facility
IP
|
$23.32
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
43701220
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$20.99 |
| Rate for Payer: Aetna of IA Commercial |
$20.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.99
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.49
|
| Rate for Payer: Medical Associates Commercial |
$17.49
|
| Rate for Payer: Midlands Choice Commercial |
$16.32
|
| Rate for Payer: United Healthcare Commercial |
$20.99
|
|
|
ampicillin 500 mg Inj SDV
|
Facility
OP
|
$23.32
|
|
|
Service Code
|
CPT J0290
|
| Hospital Charge Code |
43701220
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$20.99 |
| Rate for Payer: Aetna of IA Commercial |
$20.99
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.99
|
| Rate for Payer: Aetna of IA Medicare |
$13.29
|
| Rate for Payer: Amerigroup Medicaid |
$11.77
|
| Rate for Payer: Amerigroup Medicare |
$11.78
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.49
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.66
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.66
|
| Rate for Payer: Medical Associates Commercial |
$17.49
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.66
|
| Rate for Payer: Midlands Choice Commercial |
$16.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.49
|
| Rate for Payer: United Healthcare Commercial |
$20.99
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.76
|
|
|
ampicillin-sulbactam 1.5 GM Inj SDV
|
Facility
IP
|
$25.04
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
43722159
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.53 |
| Max. Negotiated Rate |
$22.54 |
| Rate for Payer: Aetna of IA Commercial |
$22.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.54
|
| Rate for Payer: Cash Price |
$20.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.78
|
| Rate for Payer: Medical Associates Commercial |
$18.78
|
| Rate for Payer: Midlands Choice Commercial |
$17.53
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
|
|
ampicillin-sulbactam 1.5 GM Inj SDV
|
Facility
OP
|
$25.04
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
43722159
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$22.54 |
| Rate for Payer: Aetna of IA Commercial |
$22.54
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$22.54
|
| Rate for Payer: Aetna of IA Medicare |
$14.27
|
| Rate for Payer: Amerigroup Medicaid |
$12.64
|
| Rate for Payer: Amerigroup Medicare |
$12.65
|
| Rate for Payer: Cash Price |
$20.04
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.52
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.51
|
| Rate for Payer: Medical Associates Commercial |
$18.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.52
|
| Rate for Payer: Midlands Choice Commercial |
$17.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.71
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.78
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.77
|
|
|
ampicillin-sulbactam 3 GM Inj SDV
|
Facility
IP
|
$31.59
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
43722589
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$28.43 |
| Rate for Payer: Aetna of IA Commercial |
$28.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.43
|
| Rate for Payer: Cash Price |
$25.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.69
|
| Rate for Payer: Medical Associates Commercial |
$23.69
|
| Rate for Payer: Midlands Choice Commercial |
$22.11
|
| Rate for Payer: United Healthcare Commercial |
$28.43
|
|
|
ampicillin-sulbactam 3 GM Inj SDV
|
Facility
OP
|
$31.59
|
|
|
Service Code
|
CPT J0295
|
| Hospital Charge Code |
43722589
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.79 |
| Max. Negotiated Rate |
$28.43 |
| Rate for Payer: Aetna of IA Commercial |
$28.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.43
|
| Rate for Payer: Aetna of IA Medicare |
$18.01
|
| Rate for Payer: Amerigroup Medicaid |
$15.94
|
| Rate for Payer: Amerigroup Medicare |
$15.95
|
| Rate for Payer: Cash Price |
$25.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$23.69
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$15.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$15.79
|
| Rate for Payer: Medical Associates Commercial |
$23.69
|
| Rate for Payer: Medical Associates Managed Medicare |
$15.80
|
| Rate for Payer: Midlands Choice Commercial |
$22.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$23.69
|
| Rate for Payer: United Healthcare Commercial |
$28.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.64
|
|
|
AMPUTATE METATARSAL WITH TOE SINGLE
|
Professional
|
$1,453.00
|
|
|
Service Code
|
CPT 28810
|
| Hospital Charge Code |
8825539
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$385.00 |
| Max. Negotiated Rate |
$1,017.10 |
| Rate for Payer: Aetna of IA Medicare |
$385.00
|
| Rate for Payer: Amerigroup Medicaid |
$398.09
|
| Rate for Payer: Cash Price |
$1,162.40
|
| Rate for Payer: Cash Price |
$1,162.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$462.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$392.70
|
| Rate for Payer: Medical Associates Commercial |
$731.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$385.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,017.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$577.50
|
| Rate for Payer: Wellmark IA HMO |
$802.00
|
| Rate for Payer: Wellmark IA PPO |
$941.00
|
|
|
Amputation for Circulatory System Disorders Except Upper Limb and Toe With CC
|
Facility
IP
|
$25,874.72
|
|
|
Service Code
|
MS-DRG 240
|
| Hospital Charge Code |
102
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$25,874.72 |
| Rate for Payer: Amerigroup Medicaid |
$25,749.72
|
| 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 |
$25,499.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25,874.72
|
|
|
Amputation for Circulatory System Disorders Except Upper Limb and Toe With MCC
|
Facility
IP
|
$44,251.50
|
|
|
Service Code
|
MS-DRG 239
|
| Hospital Charge Code |
101
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$44,251.50 |
| Rate for Payer: Amerigroup Medicaid |
$44,037.72
|
| 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 |
$43,610.17
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$44,251.50
|
|
|
Amputation for Circulatory System Disorders Except Upper Limb and Toe Without CC/MCC
|
Facility
IP
|
$15,667.16
|
|
|
Service Code
|
MS-DRG 241
|
| Hospital Charge Code |
103
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$15,667.16 |
| Rate for Payer: Amerigroup Medicaid |
$15,591.47
|
| 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 |
$15,440.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15,667.16
|
|
|
Amputation for Musculoskeletal System and Connective Tissue Disorders With CC
|
Facility
IP
|
$20,747.81
|
|
|
Service Code
|
MS-DRG 475
|
| Hospital Charge Code |
295
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$20,747.81 |
| Rate for Payer: Amerigroup Medicaid |
$20,647.58
|
| 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 |
$20,447.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20,747.81
|
|
|
Amputation for Musculoskeletal System and Connective Tissue Disorders With MCC
|
Facility
IP
|
$24,284.19
|
|
|
Service Code
|
MS-DRG 474
|
| Hospital Charge Code |
294
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$24,284.19 |
| Rate for Payer: Amerigroup Medicaid |
$24,166.88
|
| 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 |
$23,932.25
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24,284.19
|
|
|
Amputation for Musculoskeletal System and Connective Tissue Disorders Without CC/MCC
|
Facility
IP
|
$9,309.94
|
|
|
Service Code
|
MS-DRG 476
|
| Hospital Charge Code |
296
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$9,309.94 |
| Rate for Payer: Amerigroup Medicaid |
$9,264.96
|
| 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 |
$9,175.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9,309.94
|
|
|
Amputation, metatarsal, with toe, single
|
Facility
OP
|
$9,738.28
|
|
|
Service Code
|
CPT 28810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,852.98 |
| Max. Negotiated Rate |
$9,738.28 |
| Rate for Payer: Wellmark IA HMO |
$8,852.98
|
| Rate for Payer: Wellmark IA PPO |
$9,738.28
|
|
|
Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders With CC
|
Facility
IP
|
$15,515.58
|
|
|
Service Code
|
MS-DRG 617
|
| Hospital Charge Code |
409
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$15,515.58 |
| Rate for Payer: Amerigroup Medicaid |
$15,440.63
|
| 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 |
$15,290.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15,515.58
|
|
