|
NM Bone Imaging Whole Body
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78306
|
| Hospital Charge Code |
1169180
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Bone Marrow Imaging Multiple Areas
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78305
|
| Hospital Charge Code |
1169184
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$647.55 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$830.02
|
| Rate for Payer: Amerigroup Medicare |
$654.03
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$647.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$821.96
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$647.55
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$744.68
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Bone Marrow Imaging Multiple Areas
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78305
|
| Hospital Charge Code |
1169184
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Bone Spect
|
Facility
|
OP
|
$2,452.00
|
|
|
Service Code
|
CPT 78320
|
| Hospital Charge Code |
1169188
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,103.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Aetna of IA Medicare |
$1,397.64
|
| Rate for Payer: Amerigroup Medicaid |
$1,414.31
|
| Rate for Payer: Amerigroup Medicare |
$1,114.43
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,103.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,400.58
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,103.40
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,421.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,268.91
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,446.68
|
|
|
NM Bone Spect
|
Facility
|
IP
|
$2,452.00
|
|
|
Service Code
|
CPT 78320
|
| Hospital Charge Code |
1169188
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,716.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
|
|
NM Bone Three Phase Study
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
1169190
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Bone Three Phase Study
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78315
|
| Hospital Charge Code |
1169190
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$647.55 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$830.02
|
| Rate for Payer: Amerigroup Medicare |
$654.03
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$647.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$821.96
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$647.55
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$744.68
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Cardiac Blood Pool Gated Single
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78472
|
| Hospital Charge Code |
1169208
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$647.55 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$830.02
|
| Rate for Payer: Amerigroup Medicare |
$654.03
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$647.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$821.96
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$647.55
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$744.68
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Cardiac Blood Pool Gated Single
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78472
|
| Hospital Charge Code |
1169208
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Gastric Emptying Study
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78264
|
| Hospital Charge Code |
1169236
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$647.55 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$830.02
|
| Rate for Payer: Amerigroup Medicare |
$654.03
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$647.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$821.96
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$647.55
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$744.68
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Gastric Emptying Study
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78264
|
| Hospital Charge Code |
1169236
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Gastrointestinal Blood Loss Imaging
|
Facility
|
IP
|
$2,452.00
|
|
|
Service Code
|
CPT 78278
|
| Hospital Charge Code |
1169242
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,716.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
|
|
NM Gastrointestinal Blood Loss Imaging
|
Facility
|
OP
|
$2,452.00
|
|
|
Service Code
|
CPT 78278
|
| Hospital Charge Code |
1169242
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,103.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Aetna of IA Medicare |
$1,397.64
|
| Rate for Payer: Amerigroup Medicaid |
$1,414.31
|
| Rate for Payer: Amerigroup Medicare |
$1,114.43
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,103.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,400.58
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,103.40
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,421.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,268.91
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,446.68
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,967.48
|
| Rate for Payer: Wellmark IA PPO |
$2,167.28
|
|
|
NM Hepatobiliary Duct System Imaging
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78227
|
| Hospital Charge Code |
1169252
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Hepatobiliary Duct System Imaging
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78227
|
| Hospital Charge Code |
1169252
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$647.55 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$830.02
|
| Rate for Payer: Amerigroup Medicare |
$654.03
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$647.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$821.96
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$647.55
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$744.68
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Hepatobiliary System w/o Pharm
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78226
|
| Hospital Charge Code |
7960814
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$647.55 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$830.02
|
| Rate for Payer: Amerigroup Medicare |
$654.03
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$647.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$821.96
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$647.55
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$744.68
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Hepatobiliary System w/o Pharm
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78226
|
| Hospital Charge Code |
7960814
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Intestine Imaging
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78290
|
| Hospital Charge Code |
1169254
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$647.55 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$830.02
|
| Rate for Payer: Amerigroup Medicare |
$654.03
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$647.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$821.96
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$647.55
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$744.68
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Intestine Imaging
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78290
|
| Hospital Charge Code |
1169254
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Kidney Imaging w/ Flow w/ Pharm
|
Facility
|
OP
|
$1,439.00
|
|
|
Service Code
|
CPT 78707
|
| Hospital Charge Code |
1169262
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$647.55 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Aetna of IA Medicare |
$820.23
|
| Rate for Payer: Amerigroup Medicaid |
$830.02
|
| Rate for Payer: Amerigroup Medicare |
$654.03
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$647.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$821.96
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$647.55
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$834.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$744.68
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.01
|
| Rate for Payer: Wellmark IA HMO WHPI |
$903.27
|
| Rate for Payer: Wellmark IA PPO |
$994.99
|
|
|
NM Kidney Imaging w/ Flow w/ Pharm
|
Facility
|
IP
|
$1,439.00
|
|
|
Service Code
|
CPT 78707
|
| Hospital Charge Code |
1169262
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,007.30 |
| Max. Negotiated Rate |
$1,295.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,295.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,295.10
|
| Rate for Payer: Cash Price |
$1,151.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,079.25
|
| Rate for Payer: Medical Associates Commercial |
$1,079.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,007.30
|
| Rate for Payer: United Healthcare Commercial |
$1,295.10
|
|
|
NM Liver Imaging Spect w/ Vascular Flow
|
Facility
|
OP
|
$2,452.00
|
|
|
Service Code
|
CPT 78206
|
| Hospital Charge Code |
1169280
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,103.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Aetna of IA Medicare |
$1,397.64
|
| Rate for Payer: Amerigroup Medicaid |
$1,414.31
|
| Rate for Payer: Amerigroup Medicare |
$1,114.43
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,103.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,400.58
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,103.40
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,421.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,268.91
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,446.68
|
|
|
NM Liver Imaging Spect w/ Vascular Flow
|
Facility
|
IP
|
$2,452.00
|
|
|
Service Code
|
CPT 78206
|
| Hospital Charge Code |
1169280
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,716.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
|
|
NM Liver/Spleen Imaging
|
Facility
|
IP
|
$2,452.00
|
|
|
Service Code
|
CPT 78215
|
| Hospital Charge Code |
1169286
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,716.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
|
|
NM Liver/Spleen Imaging
|
Facility
|
OP
|
$2,452.00
|
|
|
Service Code
|
CPT 78215
|
| Hospital Charge Code |
1169286
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,103.40 |
| Max. Negotiated Rate |
$2,206.80 |
| Rate for Payer: Aetna of IA Commercial |
$2,206.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,206.80
|
| Rate for Payer: Aetna of IA Medicare |
$1,397.64
|
| Rate for Payer: Amerigroup Medicaid |
$1,414.31
|
| Rate for Payer: Amerigroup Medicare |
$1,114.43
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Cash Price |
$1,961.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,839.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,103.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,400.58
|
| Rate for Payer: Medical Associates Commercial |
$1,839.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,103.40
|
| Rate for Payer: Midlands Choice Commercial |
$1,716.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,421.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,268.91
|
| Rate for Payer: United Healthcare Commercial |
$2,206.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,446.68
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,967.48
|
| Rate for Payer: Wellmark IA PPO |
$2,167.28
|
|
