|
58660 LAP W/LYSIS OF ADHESIONS-FEMALE
|
Professional
|
Both
|
$2,237.00
|
|
|
Service Code
|
CPT 58660
|
| Hospital Charge Code |
8378884
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$623.69 |
| Max. Negotiated Rate |
$1,677.75 |
| Rate for Payer: Amerigroup Medicaid |
$629.80
|
| Rate for Payer: Cash Price |
$1,789.60
|
| Rate for Payer: Cash Price |
$1,789.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$623.69
|
| Rate for Payer: Medical Associates Commercial |
$1,677.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,565.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$626.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,677.75
|
| Rate for Payer: United Healthcare Commercial |
$1,036.14
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,298.90
|
| Rate for Payer: Wellmark IA PPO |
$1,528.10
|
|
|
58661 LAP W/SALP-OOPHORECTOMY
|
Professional
|
Both
|
$2,160.00
|
|
|
Service Code
|
CPT 58661
|
| Hospital Charge Code |
8378885
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$600.79 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Amerigroup Medicaid |
$606.68
|
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$600.79
|
| Rate for Payer: Medical Associates Commercial |
$1,620.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,512.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$603.74
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare Commercial |
$998.51
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,236.00
|
| Rate for Payer: Wellmark IA PPO |
$1,454.10
|
|
|
58662 LAP W/FULGURATION OF LESION
|
Professional
|
Both
|
$2,360.00
|
|
|
Service Code
|
CPT 58662
|
| Hospital Charge Code |
8378886
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$656.74 |
| Max. Negotiated Rate |
$1,770.00 |
| Rate for Payer: Amerigroup Medicaid |
$663.18
|
| Rate for Payer: Cash Price |
$1,888.00
|
| Rate for Payer: Cash Price |
$1,888.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$656.74
|
| Rate for Payer: Medical Associates Commercial |
$1,770.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,652.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$659.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,770.00
|
| Rate for Payer: United Healthcare Commercial |
$1,091.04
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,353.00
|
| Rate for Payer: Wellmark IA PPO |
$1,591.70
|
|
|
58670 LAP TUBAL W/ DESTRUCTION OF OVIDUCTS
|
Professional
|
Both
|
$1,207.00
|
|
|
Service Code
|
CPT 58670
|
| Hospital Charge Code |
8069144
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$336.98 |
| Max. Negotiated Rate |
$905.25 |
| Rate for Payer: Amerigroup Medicaid |
$340.28
|
| Rate for Payer: Cash Price |
$965.60
|
| Rate for Payer: Cash Price |
$965.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$336.98
|
| Rate for Payer: Medical Associates Commercial |
$905.25
|
| Rate for Payer: Midlands Choice Commercial |
$844.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$338.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$905.25
|
| Rate for Payer: United Healthcare Commercial |
$565.66
|
| Rate for Payer: Wellmark IA HMO WHPI |
$707.60
|
| Rate for Payer: Wellmark IA PPO |
$832.50
|
|
|
58671 Laparoscopy surgical; w/ occlusion of oviducts by device
|
Professional
|
Both
|
$1,197.00
|
|
|
Service Code
|
CPT 58671
|
| Hospital Charge Code |
8799204
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$336.63 |
| Max. Negotiated Rate |
$897.75 |
| Rate for Payer: Amerigroup Medicaid |
$339.93
|
| Rate for Payer: Cash Price |
$957.60
|
| Rate for Payer: Cash Price |
$957.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$336.63
|
| Rate for Payer: Medical Associates Commercial |
$897.75
|
| Rate for Payer: Midlands Choice Commercial |
$837.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$338.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$897.75
|
| Rate for Payer: United Healthcare Commercial |
$564.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$707.60
|
| Rate for Payer: Wellmark IA PPO |
$832.50
|
|
|
58720 SALPINGO-OOPHORECTOMY
|
Professional
|
Both
|
$2,459.00
|
|
|
Service Code
|
CPT 58720
|
| Hospital Charge Code |
8069040
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$654.26 |
| Max. Negotiated Rate |
$1,844.25 |
| Rate for Payer: Amerigroup Medicaid |
$660.67
|
| Rate for Payer: Cash Price |
$1,967.20
|
| Rate for Payer: Cash Price |
$1,967.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$654.26
|
| Rate for Payer: Medical Associates Commercial |
$1,844.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,721.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$657.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,844.25
|
| Rate for Payer: United Healthcare Commercial |
$1,139.22
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,444.20
|
| Rate for Payer: Wellmark IA PPO |
$1,699.00
|
|
|
58925 OVARIAN CYSTECTOMY W/HYSTERECT
|
Professional
|
Both
|
$2,484.00
|
|
|
Service Code
|
CPT 58925
|
| Hospital Charge Code |
8068997
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$637.71 |
| Max. Negotiated Rate |
$1,863.00 |
| Rate for Payer: Amerigroup Medicaid |
$643.97
|
| Rate for Payer: Cash Price |
$1,987.20
|
| Rate for Payer: Cash Price |
$1,987.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$637.71
|
| Rate for Payer: Medical Associates Commercial |
$1,863.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,738.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$640.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,863.00
|
| Rate for Payer: United Healthcare Commercial |
$1,157.39
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,456.80
|
| Rate for Payer: Wellmark IA PPO |
$1,713.80
|
|
|
58940 OOPHORECTOMY
|
Professional
|
Both
|
$1,754.00
|
|
|
Service Code
|
CPT 58940
|
| Hospital Charge Code |
8069191
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$456.72 |
| Max. Negotiated Rate |
$1,315.50 |
| Rate for Payer: Amerigroup Medicaid |
$461.19
|
| Rate for Payer: Cash Price |
$1,403.20
|
| Rate for Payer: Cash Price |
$1,403.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$456.72
|
| Rate for Payer: Medical Associates Commercial |
$1,315.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,227.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$458.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,315.50
|
| Rate for Payer: United Healthcare Commercial |
$822.78
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,056.70
|
| Rate for Payer: Wellmark IA PPO |
$1,243.20
|
|
|
59160 DC POSTPARTUM
|
Professional
|
Both
|
$682.00
|
|
|
Service Code
|
CPT 59160
|
| Hospital Charge Code |
8378906
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$212.53 |
| Max. Negotiated Rate |
$612.70 |
| Rate for Payer: Amerigroup Medicaid |
$214.61
|
| Rate for Payer: Cash Price |
$545.60
|
| Rate for Payer: Cash Price |
$545.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$212.53
|
| Rate for Payer: Medical Associates Commercial |
$511.50
|
| Rate for Payer: Midlands Choice Commercial |
$477.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$213.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$511.50
|
| Rate for Payer: United Healthcare Commercial |
$356.61
|
| Rate for Payer: Wellmark IA HMO WHPI |
$520.80
|
| Rate for Payer: Wellmark IA PPO |
$612.70
|
|
|
59514 C-SECTION
|
Professional
|
Both
|
$3,100.00
|
|
|
Service Code
|
CPT 59514
|
| Hospital Charge Code |
8069081
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$920.45 |
| Max. Negotiated Rate |
$2,325.00 |
| Rate for Payer: Amerigroup Medicaid |
$929.47
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$920.45
|
| Rate for Payer: Medical Associates Commercial |
$2,325.00
|
| Rate for Payer: Midlands Choice Commercial |
$2,170.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$924.96
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,325.00
|
| Rate for Payer: United Healthcare Commercial |
$976.99
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,105.20
|
| Rate for Payer: Wellmark IA PPO |
$1,300.20
|
|
|
59820 SURG TX MISSED ABORT 1ST TRIMESTER
|
Professional
|
Both
|
$1,273.00
|
|
|
Service Code
|
CPT 59820
|
| Hospital Charge Code |
8378888
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$296.59 |
| Max. Negotiated Rate |
$989.40 |
| Rate for Payer: Amerigroup Medicaid |
$299.49
|
| Rate for Payer: Cash Price |
$1,018.40
|
| Rate for Payer: Cash Price |
$1,018.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$296.59
|
| Rate for Payer: Medical Associates Commercial |
$954.75
|
| Rate for Payer: Midlands Choice Commercial |
$891.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$298.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$954.75
|
| Rate for Payer: United Healthcare Commercial |
$610.32
|
| Rate for Payer: Wellmark IA HMO WHPI |
$841.00
|
| Rate for Payer: Wellmark IA PPO |
$989.40
|
|
|
59820 Treatment of missed abortion- 1st trimester
|
Professional
|
Both
|
$1,270.00
|
|
|
Service Code
|
CPT 59820
|
| Hospital Charge Code |
8799205
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$296.59 |
| Max. Negotiated Rate |
$989.40 |
| Rate for Payer: Amerigroup Medicaid |
$299.49
|
| Rate for Payer: Cash Price |
$1,016.00
|
| Rate for Payer: Cash Price |
$1,016.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$296.59
|
| Rate for Payer: Medical Associates Commercial |
$952.50
|
| Rate for Payer: Midlands Choice Commercial |
$889.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$298.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$952.50
|
| Rate for Payer: United Healthcare Commercial |
$610.32
|
| Rate for Payer: Wellmark IA HMO WHPI |
$841.00
|
| Rate for Payer: Wellmark IA PPO |
$989.40
|
|
|
60220 THYROID LOBECTOMY TOTAL
|
Professional
|
Both
|
$2,370.00
|
|
|
Service Code
|
CPT 60220
|
| Hospital Charge Code |
8068978
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$656.65 |
| Max. Negotiated Rate |
$1,777.50 |
| Rate for Payer: Amerigroup Medicaid |
$663.08
|
| Rate for Payer: Cash Price |
$1,896.00
|
| Rate for Payer: Cash Price |
$1,896.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$656.65
|
| Rate for Payer: Medical Associates Commercial |
$1,777.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,659.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$659.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,777.50
|
| Rate for Payer: United Healthcare Commercial |
$1,069.02
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,340.40
|
| Rate for Payer: Wellmark IA PPO |
$1,576.90
|
|
|
62321 Spinal injection steroid- cervical/thoracic with fluoroscopic guidance
|
Professional
|
Both
|
$860.00
|
|
|
Service Code
|
CPT 62321
|
| Hospital Charge Code |
8799206
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$226.64 |
| Max. Negotiated Rate |
$645.00 |
| Rate for Payer: Amerigroup Medicaid |
$228.87
|
| Rate for Payer: Cash Price |
$688.00
|
| Rate for Payer: Cash Price |
$688.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$226.64
|
| Rate for Payer: Medical Associates Commercial |
$645.00
|
| Rate for Payer: Midlands Choice Commercial |
$602.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$227.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$645.00
|
| Rate for Payer: United Healthcare Commercial |
$391.44
|
| Rate for Payer: Wellmark IA HMO WHPI |
$494.30
|
| Rate for Payer: Wellmark IA PPO |
$581.50
|
|
|
62323 Spinal injection steroid- lumbar/sacral with fluoroscopic guidance
|
Professional
|
Both
|
$808.00
|
|
|
Service Code
|
CPT 62323
|
| Hospital Charge Code |
8799211
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$222.64 |
| Max. Negotiated Rate |
$606.00 |
| Rate for Payer: Amerigroup Medicaid |
$224.82
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$222.64
|
| Rate for Payer: Medical Associates Commercial |
$606.00
|
| Rate for Payer: Midlands Choice Commercial |
$565.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$223.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$606.00
|
| Rate for Payer: United Healthcare Commercial |
$386.45
|
| Rate for Payer: Wellmark IA HMO WHPI |
$486.10
|
| Rate for Payer: Wellmark IA PPO |
$571.90
|
|
|
64405 Occipital nerve block (can only be reported once-even if bilateral)
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
CPT 64405
|
| Hospital Charge Code |
8799212
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$97.96 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Amerigroup Medicaid |
$98.92
|
| Rate for Payer: Cash Price |
$265.60
|
| Rate for Payer: Cash Price |
$265.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$97.96
|
| Rate for Payer: Medical Associates Commercial |
$249.00
|
| Rate for Payer: Midlands Choice Commercial |
$232.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$98.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$249.00
|
| Rate for Payer: United Healthcare Commercial |
$107.60
|
| Rate for Payer: Wellmark IA HMO WHPI |
$142.20
|
| Rate for Payer: Wellmark IA PPO |
$167.30
|
|
|
64451 INJ AA/STRD Nerves NRVTG SI Joint W/IMG
|
Professional
|
Both
|
$699.00
|
|
|
Service Code
|
CPT 64451
|
| Hospital Charge Code |
8801477
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$164.89 |
| Max. Negotiated Rate |
$524.25 |
| Rate for Payer: Amerigroup Medicaid |
$166.51
|
| Rate for Payer: Cash Price |
$559.20
|
| Rate for Payer: Cash Price |
$559.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$164.89
|
| Rate for Payer: Medical Associates Commercial |
$524.25
|
| Rate for Payer: Midlands Choice Commercial |
$489.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$165.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$524.25
|
| Rate for Payer: United Healthcare Commercial |
$317.70
|
| Rate for Payer: Wellmark IA HMO WHPI |
$428.50
|
| Rate for Payer: Wellmark IA PPO |
$504.10
|
|
|
64454 Injection genicular nerve branches incl/ imaging when guidance
|
Professional
|
Both
|
$706.00
|
|
|
Service Code
|
CPT 64454
|
| Hospital Charge Code |
8799213
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$82.28 |
| Max. Negotiated Rate |
$529.50 |
| Rate for Payer: Amerigroup Medicaid |
$83.09
|
| Rate for Payer: Cash Price |
$564.80
|
| Rate for Payer: Cash Price |
$564.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$82.28
|
| Rate for Payer: Medical Associates Commercial |
$529.50
|
| Rate for Payer: Midlands Choice Commercial |
$494.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$529.50
|
| Rate for Payer: United Healthcare Commercial |
$320.83
|
| Rate for Payer: Wellmark IA HMO WHPI |
$417.20
|
| Rate for Payer: Wellmark IA PPO |
$490.80
|
|
|
64479 INJ Foramen Epidural C/T
|
Professional
|
Both
|
$847.00
|
|
|
Service Code
|
CPT 64479
|
| Hospital Charge Code |
8801475
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$203.65 |
| Max. Negotiated Rate |
$635.25 |
| Rate for Payer: Amerigroup Medicaid |
$205.65
|
| Rate for Payer: Cash Price |
$677.60
|
| Rate for Payer: Cash Price |
$677.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$203.65
|
| Rate for Payer: Medical Associates Commercial |
$635.25
|
| Rate for Payer: Midlands Choice Commercial |
$592.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$204.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$635.25
|
| Rate for Payer: United Healthcare Commercial |
$386.38
|
| Rate for Payer: Wellmark IA HMO WHPI |
$499.90
|
| Rate for Payer: Wellmark IA PPO |
$588.10
|
|
|
64480 INJ Foramen Epidural Add-On
|
Professional
|
Both
|
$421.00
|
|
|
Service Code
|
CPT 64480
|
| Hospital Charge Code |
8801476
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$182.44 |
| Max. Negotiated Rate |
$315.75 |
| Rate for Payer: Amerigroup Medicaid |
$184.23
|
| Rate for Payer: Cash Price |
$336.80
|
| Rate for Payer: Cash Price |
$336.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$182.44
|
| Rate for Payer: Medical Associates Commercial |
$315.75
|
| Rate for Payer: Midlands Choice Commercial |
$294.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$183.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$315.75
|
| Rate for Payer: United Healthcare Commercial |
$192.16
|
| Rate for Payer: Wellmark IA HMO WHPI |
$253.10
|
| Rate for Payer: Wellmark IA PPO |
$297.70
|
|
|
64561 PERCUTANEOUS IMPLANT NEUROELECTRODES
|
Professional
|
Both
|
$2,732.00
|
|
|
Service Code
|
CPT 64561
|
| Hospital Charge Code |
8068904
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$755.98 |
| Max. Negotiated Rate |
$2,049.00 |
| Rate for Payer: Amerigroup Medicaid |
$763.39
|
| Rate for Payer: Cash Price |
$2,185.60
|
| Rate for Payer: Cash Price |
$2,185.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$755.98
|
| Rate for Payer: Medical Associates Commercial |
$2,049.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,912.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$759.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$2,049.00
|
| Rate for Payer: United Healthcare Commercial |
$1,129.50
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,378.20
|
| Rate for Payer: Wellmark IA PPO |
$1,621.40
|
|
|
64581 INCISION FOR IMPLANT NEUROELECTRODES
|
Professional
|
Both
|
$2,232.00
|
|
|
Service Code
|
CPT 64581
|
| Hospital Charge Code |
8068905
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$723.30 |
| Max. Negotiated Rate |
$1,674.00 |
| Rate for Payer: Amerigroup Medicaid |
$730.39
|
| Rate for Payer: Cash Price |
$1,785.60
|
| Rate for Payer: Cash Price |
$1,785.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$723.30
|
| Rate for Payer: Medical Associates Commercial |
$1,674.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,562.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$726.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,674.00
|
| Rate for Payer: United Healthcare Commercial |
$1,025.73
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,229.10
|
| Rate for Payer: Wellmark IA PPO |
$1,446.00
|
|
|
64590 INSERTION/REPLACEMENT OF NEUROSTIMULATOR GEN OR REC
|
Professional
|
Both
|
$882.00
|
|
|
Service Code
|
CPT 64590
|
| Hospital Charge Code |
8068906
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$165.50 |
| Max. Negotiated Rate |
$978.00 |
| Rate for Payer: Amerigroup Medicaid |
$167.12
|
| Rate for Payer: Cash Price |
$705.60
|
| Rate for Payer: Cash Price |
$705.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$165.50
|
| Rate for Payer: Medical Associates Commercial |
$661.50
|
| Rate for Payer: Midlands Choice Commercial |
$617.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$166.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$661.50
|
| Rate for Payer: United Healthcare Commercial |
$400.66
|
| Rate for Payer: Wellmark IA HMO WHPI |
$831.30
|
| Rate for Payer: Wellmark IA PPO |
$978.00
|
|
|
64624 Destruction by neurolytic agent genicular nerve branches inc imaging guidance
|
Professional
|
Both
|
$1,350.00
|
|
|
Service Code
|
CPT 64624
|
| Hospital Charge Code |
8799214
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$612.69 |
| Max. Negotiated Rate |
$1,012.50 |
| Rate for Payer: Cash Price |
$1,080.00
|
| Rate for Payer: Cash Price |
$1,080.00
|
| Rate for Payer: Medical Associates Commercial |
$1,012.50
|
| Rate for Payer: Midlands Choice Commercial |
$945.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,012.50
|
| Rate for Payer: United Healthcare Commercial |
$612.69
|
| Rate for Payer: Wellmark IA HMO WHPI |
$730.40
|
| Rate for Payer: Wellmark IA PPO |
$859.30
|
|
|
64625 Radiofrequency ablation of sacroiliac joint
|
Professional
|
Both
|
$1,649.00
|
|
|
Service Code
|
CPT 64625
|
| Hospital Charge Code |
8801481
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$749.84 |
| Max. Negotiated Rate |
$1,236.75 |
| Rate for Payer: Cash Price |
$1,319.20
|
| Rate for Payer: Cash Price |
$1,319.20
|
| Rate for Payer: Medical Associates Commercial |
$1,236.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,154.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,236.75
|
| Rate for Payer: United Healthcare Commercial |
$749.84
|
| Rate for Payer: Wellmark IA HMO WHPI |
$888.90
|
| Rate for Payer: Wellmark IA PPO |
$1,045.80
|
|
