|
Deep Vein Thrombophlebitis With CC/MCC
|
Facility
IP
|
$12,621.92
|
|
|
Service Code
|
MS-DRG 294
|
| Hospital Charge Code |
151
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$12,621.92 |
| Rate for Payer: Amerigroup Medicaid |
$12,560.94
|
| 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 |
$12,438.99
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12,621.92
|
|
|
Deep Vein Thrombophlebitis Without CC/MCC
|
Facility
IP
|
$9,658.36
|
|
|
Service Code
|
MS-DRG 295
|
| Hospital Charge Code |
152
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$9,658.36 |
| Rate for Payer: Amerigroup Medicaid |
$9,611.70
|
| 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 |
$9,518.38
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9,658.36
|
|
|
deferoxamine 2 g Pow SDV
|
Facility
IP
|
$137.94
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
43768817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.56 |
| Max. Negotiated Rate |
$124.15 |
| Rate for Payer: Aetna of IA Commercial |
$124.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$124.15
|
| Rate for Payer: Cash Price |
$110.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$103.46
|
| Rate for Payer: Medical Associates Commercial |
$103.46
|
| Rate for Payer: Midlands Choice Commercial |
$96.56
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
|
|
deferoxamine 2 g Pow SDV
|
Facility
OP
|
$137.94
|
|
|
Service Code
|
CPT J0895
|
| Hospital Charge Code |
43768817
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.94 |
| Max. Negotiated Rate |
$124.15 |
| Rate for Payer: Aetna of IA Commercial |
$124.15
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$124.15
|
| Rate for Payer: Aetna of IA Medicare |
$78.63
|
| Rate for Payer: Amerigroup Medicaid |
$69.62
|
| Rate for Payer: Amerigroup Medicare |
$69.66
|
| Rate for Payer: Cash Price |
$110.35
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$103.46
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$68.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$68.94
|
| Rate for Payer: Medical Associates Commercial |
$103.46
|
| Rate for Payer: Medical Associates Managed Medicare |
$68.97
|
| Rate for Payer: Midlands Choice Commercial |
$96.56
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$103.46
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Managed Medicare |
$81.38
|
|
|
Degenerative Nervous System Disorders With MCC
|
Facility
IP
|
$20,532.26
|
|
|
Service Code
|
MS-DRG 056
|
| Hospital Charge Code |
736
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$20,532.26 |
| Rate for Payer: Amerigroup Medicaid |
$20,433.07
|
| 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 |
$20,234.69
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20,532.26
|
|
|
Degenerative Nervous System Disorders Without MCC
|
Facility
IP
|
$16,397.46
|
|
|
Service Code
|
MS-DRG 057
|
| Hospital Charge Code |
737
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$16,397.46 |
| Rate for Payer: Amerigroup Medicaid |
$16,318.25
|
| 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 |
$16,159.82
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16,397.46
|
|
|
Dehydroepiandrosterone Sulfate DMCL
|
Facility
IP
|
$135.00
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
8037835
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$121.50 |
| Rate for Payer: Aetna of IA Commercial |
$121.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.50
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$101.25
|
| Rate for Payer: Medical Associates Commercial |
$101.25
|
| Rate for Payer: Midlands Choice Commercial |
$94.50
|
| Rate for Payer: United Healthcare Commercial |
$121.50
|
|
|
Dehydroepiandrosterone Sulfate DMCL
|
Facility
OP
|
$135.00
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
8037835
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$121.50 |
| Rate for Payer: Aetna of IA Commercial |
$121.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$121.50
|
| Rate for Payer: Aetna of IA Medicare |
$76.95
|
| Rate for Payer: Amerigroup Medicaid |
$68.13
|
| Rate for Payer: Amerigroup Medicare |
$68.18
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$101.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.47
|
| Rate for Payer: Medical Associates Commercial |
$101.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.50
|
| Rate for Payer: Midlands Choice Commercial |
$94.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.51
|
| Rate for Payer: Partners Health Alliance Commercial |
$101.25
|
| Rate for Payer: United Healthcare Commercial |
$121.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$79.65
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
denosumab 60 mg/mL 1 ml SDV inj
|
Facility
OP
|
$3,451.70
|
|
|
Service Code
|
CPT J0897
|
| Hospital Charge Code |
43700165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,725.16 |
| Max. Negotiated Rate |
$3,106.53 |
| Rate for Payer: Aetna of IA Commercial |
$3,106.53
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,106.53
|
| Rate for Payer: Aetna of IA Medicare |
$1,967.47
|
| Rate for Payer: Amerigroup Medicaid |
$1,742.07
|
| Rate for Payer: Amerigroup Medicare |
$1,743.11
|
| Rate for Payer: Cash Price |
$2,761.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,588.78
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,725.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,725.16
|
| Rate for Payer: Medical Associates Commercial |
$2,588.78
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,725.85
|
| Rate for Payer: Midlands Choice Commercial |
$2,416.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,751.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,588.78
|
| Rate for Payer: United Healthcare Commercial |
$3,106.53
|
| Rate for Payer: United Healthcare Managed Medicare |
$2,036.50
|
|
|
denosumab 60 mg/mL 1 ml SDV inj
|
Facility
IP
|
$3,451.70
|
|
|
Service Code
|
CPT J0897
|
| Hospital Charge Code |
43700165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,416.19 |
| Max. Negotiated Rate |
$3,106.53 |
| Rate for Payer: Aetna of IA Commercial |
$3,106.53
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3,106.53
|
| Rate for Payer: Cash Price |
$2,761.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2,588.78
|
| Rate for Payer: Medical Associates Commercial |
$2,588.78
|
| Rate for Payer: Midlands Choice Commercial |
$2,416.19
|
| Rate for Payer: United Healthcare Commercial |
$3,106.53
|
|
|
Dental and Oral Diseases With CC
|
Facility
IP
|
$7,578.66
|
|
|
Service Code
|
MS-DRG 158
|
| Hospital Charge Code |
38
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$7,578.66 |
| Rate for Payer: Amerigroup Medicaid |
$7,542.05
|
| 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 |
$7,468.83
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7,578.66
|
|
|
Dental and Oral Diseases With MCC
|
Facility
IP
|
$11,818.77
|
|
|
Service Code
|
MS-DRG 157
|
| Hospital Charge Code |
37
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$11,818.77 |
| Rate for Payer: Amerigroup Medicaid |
$11,761.67
|
| 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 |
$11,647.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11,818.77
|
|
|
Dental and Oral Diseases Without CC/MCC
|
Facility
IP
|
$6,486.15
|
|
|
Service Code
|
MS-DRG 159
|
| Hospital Charge Code |
39
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$6,486.15 |
| Rate for Payer: Amerigroup Medicaid |
$6,454.81
|
| 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 |
$6,392.15
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,486.15
|
|
|
Dentemp
|
Facility
IP
|
$18.36
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43714328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.85 |
| Max. Negotiated Rate |
$16.52 |
| Rate for Payer: Aetna of IA Commercial |
$16.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.52
|
| Rate for Payer: Cash Price |
$14.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.77
|
| Rate for Payer: Medical Associates Commercial |
$13.77
|
| Rate for Payer: Midlands Choice Commercial |
$12.85
|
| Rate for Payer: United Healthcare Commercial |
$16.52
|
|
|
Dentemp
|
Facility
OP
|
$18.36
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43714328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$16.52 |
| Rate for Payer: Aetna of IA Commercial |
$16.52
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$16.52
|
| Rate for Payer: Aetna of IA Medicare |
$10.47
|
| Rate for Payer: Amerigroup Medicaid |
$9.27
|
| Rate for Payer: Amerigroup Medicare |
$9.27
|
| Rate for Payer: Cash Price |
$14.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$13.77
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$9.18
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9.18
|
| Rate for Payer: Medical Associates Commercial |
$13.77
|
| Rate for Payer: Medical Associates Managed Medicare |
$9.18
|
| Rate for Payer: Midlands Choice Commercial |
$12.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$9.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$13.77
|
| Rate for Payer: United Healthcare Commercial |
$16.52
|
| Rate for Payer: United Healthcare Managed Medicare |
$10.83
|
|
|
Depressive Neuroses
|
Facility
IP
|
$5,690.89
|
|
|
Service Code
|
MS-DRG 881
|
| Hospital Charge Code |
611
|
| Min. Negotiated Rate |
$2,034.00 |
| Max. Negotiated Rate |
$5,690.89 |
| Rate for Payer: Amerigroup Medicaid |
$5,663.39
|
| 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 |
$5,608.41
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$5,690.89
|
|
|
desmopressin 0.2 mg Tab
|
Facility
IP
|
$3.92
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43755033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Aetna of IA Commercial |
$3.53
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.53
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.94
|
| Rate for Payer: Medical Associates Commercial |
$2.94
|
| Rate for Payer: Midlands Choice Commercial |
$2.74
|
| Rate for Payer: United Healthcare Commercial |
$3.53
|
|
|
desmopressin 0.2 mg Tab
|
Facility
OP
|
$3.92
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43755033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Aetna of IA Commercial |
$3.53
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.53
|
| Rate for Payer: Aetna of IA Medicare |
$2.23
|
| Rate for Payer: Amerigroup Medicaid |
$1.98
|
| Rate for Payer: Amerigroup Medicare |
$1.98
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.96
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.96
|
| Rate for Payer: Medical Associates Commercial |
$2.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.96
|
| Rate for Payer: Midlands Choice Commercial |
$2.74
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.94
|
| Rate for Payer: United Healthcare Commercial |
$3.53
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.31
|
|
|
desmopressin 4 mcg/mL 1 ml SDV inj
|
Facility
OP
|
$201.49
|
|
|
Service Code
|
CPT J2597
|
| Hospital Charge Code |
43770335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.70 |
| Max. Negotiated Rate |
$181.34 |
| Rate for Payer: Aetna of IA Commercial |
$181.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$181.34
|
| Rate for Payer: Aetna of IA Medicare |
$114.85
|
| Rate for Payer: Amerigroup Medicaid |
$101.69
|
| Rate for Payer: Amerigroup Medicare |
$101.75
|
| Rate for Payer: Cash Price |
$161.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$151.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$100.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.70
|
| Rate for Payer: Medical Associates Commercial |
$151.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$100.74
|
| Rate for Payer: Midlands Choice Commercial |
$141.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$151.12
|
| Rate for Payer: United Healthcare Commercial |
$181.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$118.88
|
|
|
desmopressin 4 mcg/mL 1 ml SDV inj
|
Facility
IP
|
$201.49
|
|
|
Service Code
|
CPT J2597
|
| Hospital Charge Code |
43770335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.04 |
| Max. Negotiated Rate |
$181.34 |
| Rate for Payer: Aetna of IA Commercial |
$181.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$181.34
|
| Rate for Payer: Cash Price |
$161.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$151.12
|
| Rate for Payer: Medical Associates Commercial |
$151.12
|
| Rate for Payer: Midlands Choice Commercial |
$141.04
|
| Rate for Payer: United Healthcare Commercial |
$181.34
|
|
|
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
|
Facility
OP
|
$1,560.42
|
|
|
Service Code
|
CPT 64624
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,418.56 |
| Max. Negotiated Rate |
$1,560.42 |
| Rate for Payer: Wellmark IA HMO |
$1,418.56
|
| Rate for Payer: Wellmark IA PPO |
$1,560.42
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
|
Facility
OP
|
$1,487.44
|
|
|
Service Code
|
CPT 64634
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,352.22 |
| Max. Negotiated Rate |
$1,487.44 |
| Rate for Payer: Wellmark IA HMO |
$1,352.22
|
| Rate for Payer: Wellmark IA PPO |
$1,487.44
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
|
Facility
OP
|
$1,487.44
|
|
|
Service Code
|
CPT 64633
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,352.22 |
| Max. Negotiated Rate |
$1,487.44 |
| Rate for Payer: Wellmark IA HMO |
$1,352.22
|
| Rate for Payer: Wellmark IA PPO |
$1,487.44
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
|
Facility
OP
|
$1,487.44
|
|
|
Service Code
|
CPT 64636
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,352.22 |
| Max. Negotiated Rate |
$1,487.44 |
| Rate for Payer: Wellmark IA HMO |
$1,352.22
|
| Rate for Payer: Wellmark IA PPO |
$1,487.44
|
|
|
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
|
Facility
OP
|
$1,487.44
|
|
|
Service Code
|
CPT 64635
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,352.22 |
| Max. Negotiated Rate |
$1,487.44 |
| Rate for Payer: Wellmark IA HMO |
$1,352.22
|
| Rate for Payer: Wellmark IA PPO |
$1,487.44
|
|
