Uterine and Adnexa Procedures for Non-ovarian and Non-adnexal Malignancy With CC
|
Facility
IP
|
$15,428.97
|
|
Service Code
|
MS-DRG 740
|
Hospital Charge Code |
501
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$15,428.97 |
Rate for Payer: Amerigroup Medicaid |
$15,354.44
|
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 |
$15,205.36
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$15,428.97
|
|
Uterine and Adnexa Procedures for Non-ovarian and Non-adnexal Malignancy With MCC
|
Facility
IP
|
$37,624.60
|
|
Service Code
|
MS-DRG 739
|
Hospital Charge Code |
500
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$37,624.60 |
Rate for Payer: Amerigroup Medicaid |
$37,442.84
|
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 |
$37,079.32
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$37,624.60
|
|
Uterine and Adnexa Procedures for Non-ovarian and Non-adnexal Malignancy Without CC/MCC
|
Facility
IP
|
$12,583.53
|
|
Service Code
|
MS-DRG 741
|
Hospital Charge Code |
502
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$12,583.53 |
Rate for Payer: Amerigroup Medicaid |
$12,522.74
|
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 |
$12,401.16
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$12,583.53
|
|
Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy With CC
|
Facility
IP
|
$17,488.98
|
|
Service Code
|
MS-DRG 737
|
Hospital Charge Code |
498
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$17,488.98 |
Rate for Payer: Amerigroup Medicaid |
$17,404.50
|
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 |
$17,235.52
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$17,488.98
|
|
Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy With MCC
|
Facility
IP
|
$41,921.80
|
|
Service Code
|
MS-DRG 736
|
Hospital Charge Code |
497
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$41,921.80 |
Rate for Payer: Amerigroup Medicaid |
$41,719.27
|
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 |
$41,314.23
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$41,921.80
|
|
Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy Without CC/MCC
|
Facility
IP
|
$14,052.02
|
|
Service Code
|
MS-DRG 738
|
Hospital Charge Code |
499
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$14,052.02 |
Rate for Payer: Amerigroup Medicaid |
$13,984.13
|
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 |
$13,848.37
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$14,052.02
|
|
Vagina, Cervix and Vulva Procedures With CC/MCC
|
Facility
IP
|
$9,810.92
|
|
Service Code
|
MS-DRG 746
|
Hospital Charge Code |
507
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$9,810.92 |
Rate for Payer: Amerigroup Medicaid |
$9,763.52
|
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 |
$9,668.73
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$9,810.92
|
|
Vagina, Cervix and Vulva Procedures Without CC/MCC
|
Facility
IP
|
$8,658.38
|
|
Service Code
|
MS-DRG 747
|
Hospital Charge Code |
508
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$8,658.38 |
Rate for Payer: Amerigroup Medicaid |
$8,616.55
|
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 |
$8,532.89
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$8,658.38
|
|
Vaginal Delivery With O.R. Procedures Except Sterilization And/or D&C
|
Facility
IP
|
$6,571.78
|
|
Service Code
|
MS-DRG 768
|
Hospital Charge Code |
520
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$6,571.78 |
Rate for Payer: Amerigroup Medicaid |
$6,540.04
|
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 |
$6,476.54
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$6,571.78
|
|
Vaginal Delivery Without Sterilization or D&C With CC
|
Facility
IP
|
$6,251.91
|
|
Service Code
|
MS-DRG 806
|
Hospital Charge Code |
548
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$6,251.91 |
Rate for Payer: Amerigroup Medicaid |
$6,221.70
|
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 |
$6,161.30
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$6,251.91
|
|
Vaginal Delivery Without Sterilization or D&C With MCC
|
Facility
IP
|
$6,913.31
|
|
Service Code
|
MS-DRG 805
|
Hospital Charge Code |
547
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$6,913.31 |
Rate for Payer: Amerigroup Medicaid |
$6,879.92
|
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 |
$6,813.12
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$6,913.31
|
|
Vaginal Delivery Without Sterilization or D&C Without CC/MCC
|
Facility
IP
|
$5,867.06
|
|
Service Code
|
MS-DRG 807
|
Hospital Charge Code |
549
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$5,867.06 |
Rate for Payer: Amerigroup Medicaid |
$5,838.72
|
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 |
$5,782.03
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$5,867.06
|
|
Vaginal Delivery With Sterilization And/or D&C With CC
|
Facility
IP
|
$8,442.83
|
|
Service Code
|
MS-DRG 797
|
Hospital Charge Code |
539
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$8,442.83 |
Rate for Payer: Amerigroup Medicaid |
$8,402.04
|
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 |
$8,320.47
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$8,442.83
|
|
Vaginal Delivery With Sterilization And/or D&C With MCC
|
Facility
IP
|
$9,267.62
|
|
Service Code
|
MS-DRG 796
|
Hospital Charge Code |
538
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$9,267.62 |
Rate for Payer: Amerigroup Medicaid |
$9,222.85
|
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 |
$9,133.30
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$9,267.62
|
|
Vaginal Delivery With Sterilization And/or D&C Without CC/MCC
|
Facility
IP
|
$8,020.59
|
|
Service Code
|
MS-DRG 798
|
Hospital Charge Code |
540
|
Min. Negotiated Rate |
$2,034.00 |
Max. Negotiated Rate |
$8,020.59 |
Rate for Payer: Amerigroup Medicaid |
$7,981.84
|
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 |
$7,904.35
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$8,020.59
|
|
valACYclovir 500 mg Tab
|
Facility
IP
|
$1.75
|
|
Service Code
|
CPT A9270
|
Hospital Charge Code |
43700212
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$1.22 |
Max. Negotiated Rate |
$1.58 |
Rate for Payer: Aetna of IA Commercial |
$1.58
|
Rate for Payer: Aetna of IA Medical Rental Products |
$1.58
|
Rate for Payer: Cash Price |
$1.40
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.31
|
Rate for Payer: Medical Associates Commercial |
$1.31
|
Rate for Payer: Midlands Choice Commercial |
$1.22
|
Rate for Payer: United Healthcare Commercial |
$1.58
|
|
valACYclovir 500 mg Tab
|
Facility
OP
|
$1.75
|
|
Service Code
|
CPT A9270
|
Hospital Charge Code |
43700212
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.87 |
Max. Negotiated Rate |
$1.58 |
Rate for Payer: Aetna of IA Commercial |
$1.58
|
Rate for Payer: Aetna of IA Medical Rental Products |
$1.58
|
Rate for Payer: Aetna of IA Medicare |
$1.00
|
Rate for Payer: Amerigroup Medicaid |
$0.88
|
Rate for Payer: Amerigroup Medicare |
$0.88
|
Rate for Payer: Cash Price |
$1.40
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.31
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.88
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$0.87
|
Rate for Payer: Medical Associates Commercial |
$1.31
|
Rate for Payer: Medical Associates Managed Medicare |
$0.88
|
Rate for Payer: Midlands Choice Commercial |
$1.22
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$0.89
|
Rate for Payer: Partners Health Alliance Commercial |
$1.31
|
Rate for Payer: United Healthcare Commercial |
$1.58
|
Rate for Payer: United Healthcare Managed Medicare |
$1.03
|
|
valGANciclovir 450 mg Tab
|
Facility
IP
|
$12.84
|
|
Service Code
|
CPT A9270
|
Hospital Charge Code |
43705850
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$8.99 |
Max. Negotiated Rate |
$11.56 |
Rate for Payer: Aetna of IA Commercial |
$11.56
|
Rate for Payer: Aetna of IA Medical Rental Products |
$11.56
|
Rate for Payer: Cash Price |
$10.27
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.63
|
Rate for Payer: Medical Associates Commercial |
$9.63
|
Rate for Payer: Midlands Choice Commercial |
$8.99
|
Rate for Payer: United Healthcare Commercial |
$11.56
|
|
valGANciclovir 450 mg Tab
|
Facility
OP
|
$12.84
|
|
Service Code
|
CPT A9270
|
Hospital Charge Code |
43705850
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$6.42 |
Max. Negotiated Rate |
$11.56 |
Rate for Payer: Aetna of IA Commercial |
$11.56
|
Rate for Payer: Aetna of IA Medical Rental Products |
$11.56
|
Rate for Payer: Aetna of IA Medicare |
$7.32
|
Rate for Payer: Amerigroup Medicaid |
$6.48
|
Rate for Payer: Amerigroup Medicare |
$6.48
|
Rate for Payer: Cash Price |
$10.27
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.63
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.42
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$6.42
|
Rate for Payer: Medical Associates Commercial |
$9.63
|
Rate for Payer: Medical Associates Managed Medicare |
$6.42
|
Rate for Payer: Midlands Choice Commercial |
$8.99
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$6.52
|
Rate for Payer: Partners Health Alliance Commercial |
$9.63
|
Rate for Payer: United Healthcare Commercial |
$11.56
|
Rate for Payer: United Healthcare Managed Medicare |
$7.58
|
|
valproic acid 250 mg/5 mL Oral Syrup
|
Facility
OP
|
$5.59
|
|
Service Code
|
CPT J3490
|
Hospital Charge Code |
43705964
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.79 |
Max. Negotiated Rate |
$5.03 |
Rate for Payer: Aetna of IA Commercial |
$5.03
|
Rate for Payer: Aetna of IA Medical Rental Products |
$5.03
|
Rate for Payer: Aetna of IA Medicare |
$3.19
|
Rate for Payer: Amerigroup Medicaid |
$2.82
|
Rate for Payer: Amerigroup Medicare |
$2.82
|
Rate for Payer: Cash Price |
$4.47
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.19
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.80
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$2.79
|
Rate for Payer: Medical Associates Commercial |
$4.19
|
Rate for Payer: Medical Associates Managed Medicare |
$2.80
|
Rate for Payer: Midlands Choice Commercial |
$3.91
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$2.84
|
Rate for Payer: Partners Health Alliance Commercial |
$4.19
|
Rate for Payer: United Healthcare Commercial |
$5.03
|
Rate for Payer: United Healthcare Managed Medicare |
$3.30
|
|
valproic acid 250 mg/5 mL Oral Syrup
|
Facility
IP
|
$5.59
|
|
Service Code
|
CPT J3490
|
Hospital Charge Code |
43705964
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$3.91 |
Max. Negotiated Rate |
$5.03 |
Rate for Payer: Aetna of IA Commercial |
$5.03
|
Rate for Payer: Aetna of IA Medical Rental Products |
$5.03
|
Rate for Payer: Cash Price |
$4.47
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.19
|
Rate for Payer: Medical Associates Commercial |
$4.19
|
Rate for Payer: Midlands Choice Commercial |
$3.91
|
Rate for Payer: United Healthcare Commercial |
$5.03
|
|
valproic acid 500 mg/5mL Sol SDV
|
Facility
OP
|
$27.21
|
|
Service Code
|
CPT A9270
|
Hospital Charge Code |
43706102
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$13.60 |
Max. Negotiated Rate |
$24.49 |
Rate for Payer: Aetna of IA Commercial |
$24.49
|
Rate for Payer: Aetna of IA Medical Rental Products |
$24.49
|
Rate for Payer: Aetna of IA Medicare |
$15.51
|
Rate for Payer: Amerigroup Medicaid |
$13.73
|
Rate for Payer: Amerigroup Medicare |
$13.74
|
Rate for Payer: Cash Price |
$21.77
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.41
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.60
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$13.60
|
Rate for Payer: Medical Associates Commercial |
$20.41
|
Rate for Payer: Medical Associates Managed Medicare |
$13.60
|
Rate for Payer: Midlands Choice Commercial |
$19.05
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$13.81
|
Rate for Payer: Partners Health Alliance Commercial |
$20.41
|
Rate for Payer: United Healthcare Commercial |
$24.49
|
Rate for Payer: United Healthcare Managed Medicare |
$16.05
|
|
valproic acid 500 mg/5mL Sol SDV
|
Facility
IP
|
$27.21
|
|
Service Code
|
CPT A9270
|
Hospital Charge Code |
43706102
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$19.05 |
Max. Negotiated Rate |
$24.49 |
Rate for Payer: Aetna of IA Commercial |
$24.49
|
Rate for Payer: Aetna of IA Medical Rental Products |
$24.49
|
Rate for Payer: Cash Price |
$21.77
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.41
|
Rate for Payer: Medical Associates Commercial |
$20.41
|
Rate for Payer: Midlands Choice Commercial |
$19.05
|
Rate for Payer: United Healthcare Commercial |
$24.49
|
|
Valproic Acid Level DMCL
|
Facility
IP
|
$129.00
|
|
Service Code
|
CPT 80164
|
Hospital Charge Code |
8037821
|
Hospital Revenue Code
|
301
|
Min. Negotiated Rate |
$90.30 |
Max. Negotiated Rate |
$116.10 |
Rate for Payer: Aetna of IA Commercial |
$116.10
|
Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
Rate for Payer: Cash Price |
$103.20
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
Rate for Payer: Medical Associates Commercial |
$96.75
|
Rate for Payer: Midlands Choice Commercial |
$90.30
|
Rate for Payer: United Healthcare Commercial |
$116.10
|
|
Valproic Acid Level DMCL
|
Facility
OP
|
$129.00
|
|
Service Code
|
CPT 80164
|
Hospital Charge Code |
8037821
|
Hospital Revenue Code
|
301
|
Min. Negotiated Rate |
$49.60 |
Max. Negotiated Rate |
$116.10 |
Rate for Payer: Aetna of IA Commercial |
$116.10
|
Rate for Payer: Aetna of IA Medical Rental Products |
$116.10
|
Rate for Payer: Aetna of IA Medicare |
$73.53
|
Rate for Payer: Amerigroup Medicaid |
$65.11
|
Rate for Payer: Amerigroup Medicare |
$65.14
|
Rate for Payer: Cash Price |
$103.20
|
Rate for Payer: Cash Price |
$103.20
|
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$96.75
|
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$64.50
|
Rate for Payer: Iowa Total Care Managed Medicaid |
$64.47
|
Rate for Payer: Medical Associates Commercial |
$96.75
|
Rate for Payer: Medical Associates Managed Medicare |
$64.50
|
Rate for Payer: Midlands Choice Commercial |
$90.30
|
Rate for Payer: Molina Healthcare Managed Medicaid |
$65.47
|
Rate for Payer: Partners Health Alliance Commercial |
$96.75
|
Rate for Payer: United Healthcare Commercial |
$116.10
|
Rate for Payer: United Healthcare Managed Medicare |
$76.11
|
Rate for Payer: Wellmark IA HMO |
$49.60
|
Rate for Payer: Wellmark IA PPO |
$54.56
|
|