|
CT Shoulder w/ + w/o Contrast Left
|
Facility
IP
|
$1,321.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
1168208
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$924.70 |
| Max. Negotiated Rate |
$1,188.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,188.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,188.90
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$990.75
|
| Rate for Payer: Medical Associates Commercial |
$990.75
|
| Rate for Payer: Midlands Choice Commercial |
$924.70
|
| Rate for Payer: United Healthcare Commercial |
$1,188.90
|
|
|
CT Shoulder w/ + w/o Contrast Left
|
Facility
OP
|
$1,321.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
1168208
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$660.24 |
| Max. Negotiated Rate |
$1,188.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,188.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,188.90
|
| Rate for Payer: Aetna of IA Medicare |
$752.97
|
| Rate for Payer: Amerigroup Medicaid |
$666.71
|
| Rate for Payer: Amerigroup Medicare |
$667.10
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$990.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$660.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$660.24
|
| Rate for Payer: Medical Associates Commercial |
$990.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$660.50
|
| Rate for Payer: Midlands Choice Commercial |
$924.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$670.41
|
| Rate for Payer: Partners Health Alliance Commercial |
$990.75
|
| Rate for Payer: United Healthcare Commercial |
$1,188.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$779.39
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Shoulder w/ + w/o Contrast Right
|
Facility
IP
|
$1,321.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
1168210
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$924.70 |
| Max. Negotiated Rate |
$1,188.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,188.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,188.90
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$990.75
|
| Rate for Payer: Medical Associates Commercial |
$990.75
|
| Rate for Payer: Midlands Choice Commercial |
$924.70
|
| Rate for Payer: United Healthcare Commercial |
$1,188.90
|
|
|
CT Shoulder w/ + w/o Contrast Right
|
Facility
OP
|
$1,321.00
|
|
|
Service Code
|
CPT 73202
|
| Hospital Charge Code |
1168210
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$660.24 |
| Max. Negotiated Rate |
$1,188.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,188.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,188.90
|
| Rate for Payer: Aetna of IA Medicare |
$752.97
|
| Rate for Payer: Amerigroup Medicaid |
$666.71
|
| Rate for Payer: Amerigroup Medicare |
$667.10
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$990.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$660.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$660.24
|
| Rate for Payer: Medical Associates Commercial |
$990.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$660.50
|
| Rate for Payer: Midlands Choice Commercial |
$924.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$670.41
|
| Rate for Payer: Partners Health Alliance Commercial |
$990.75
|
| Rate for Payer: United Healthcare Commercial |
$1,188.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$779.39
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Sinus w/ Contrast
|
Facility
IP
|
$1,540.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
1168226
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,078.00 |
| Max. Negotiated Rate |
$1,386.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,386.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,386.00
|
| Rate for Payer: Cash Price |
$1,232.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,155.00
|
| Rate for Payer: Medical Associates Commercial |
$1,155.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,078.00
|
| Rate for Payer: United Healthcare Commercial |
$1,386.00
|
|
|
CT Sinus w/ Contrast
|
Facility
OP
|
$1,540.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
1168226
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$769.69 |
| Max. Negotiated Rate |
$1,386.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,386.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,386.00
|
| Rate for Payer: Aetna of IA Medicare |
$877.80
|
| Rate for Payer: Amerigroup Medicaid |
$777.24
|
| Rate for Payer: Amerigroup Medicare |
$777.70
|
| Rate for Payer: Cash Price |
$1,232.00
|
| Rate for Payer: Cash Price |
$1,232.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,155.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$770.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$769.69
|
| Rate for Payer: Medical Associates Commercial |
$1,155.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$770.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,078.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$781.55
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,155.00
|
| Rate for Payer: United Healthcare Commercial |
$1,386.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$908.60
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Sinus w/o Contrast
|
Facility
IP
|
$1,180.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
1168228
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$826.00 |
| Max. Negotiated Rate |
$1,062.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,062.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,062.00
|
| Rate for Payer: Cash Price |
$944.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$885.00
|
| Rate for Payer: Medical Associates Commercial |
$885.00
|
| Rate for Payer: Midlands Choice Commercial |
$826.00
|
| Rate for Payer: United Healthcare Commercial |
$1,062.00
|
|
|
CT Sinus w/o Contrast
|
Facility
OP
|
$1,180.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
1168228
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$480.50 |
| Max. Negotiated Rate |
$1,062.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,062.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,062.00
|
| Rate for Payer: Aetna of IA Medicare |
$672.60
|
| Rate for Payer: Amerigroup Medicaid |
$595.55
|
| Rate for Payer: Amerigroup Medicare |
$595.90
|
| Rate for Payer: Cash Price |
$944.00
|
| Rate for Payer: Cash Price |
$944.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$885.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$590.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$589.76
|
| Rate for Payer: Medical Associates Commercial |
$885.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$590.00
|
| Rate for Payer: Midlands Choice Commercial |
$826.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$598.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$885.00
|
| Rate for Payer: United Healthcare Commercial |
$1,062.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$696.20
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
|
CT Sinus w/ + w/o Contrast
|
Facility
OP
|
$1,503.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
1168224
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$751.20 |
| Max. Negotiated Rate |
$1,352.70 |
| Rate for Payer: Aetna of IA Commercial |
$1,352.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,352.70
|
| Rate for Payer: Aetna of IA Medicare |
$856.71
|
| Rate for Payer: Amerigroup Medicaid |
$758.56
|
| Rate for Payer: Amerigroup Medicare |
$759.02
|
| Rate for Payer: Cash Price |
$1,202.40
|
| Rate for Payer: Cash Price |
$1,202.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,127.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$751.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$751.20
|
| Rate for Payer: Medical Associates Commercial |
$1,127.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$751.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,052.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$762.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,127.25
|
| Rate for Payer: United Healthcare Commercial |
$1,352.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$886.77
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Sinus w/ + w/o Contrast
|
Facility
IP
|
$1,503.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
1168224
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,052.10 |
| Max. Negotiated Rate |
$1,352.70 |
| Rate for Payer: Aetna of IA Commercial |
$1,352.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,352.70
|
| Rate for Payer: Cash Price |
$1,202.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,127.25
|
| Rate for Payer: Medical Associates Commercial |
$1,127.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,052.10
|
| Rate for Payer: United Healthcare Commercial |
$1,352.70
|
|
|
CT Soft Tissue Neck w/ Contrast
|
Facility
IP
|
$1,445.00
|
|
|
Service Code
|
CPT 70491
|
| Hospital Charge Code |
1168232
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,011.50 |
| Max. Negotiated Rate |
$1,300.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,300.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,300.50
|
| Rate for Payer: Cash Price |
$1,156.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,083.75
|
| Rate for Payer: Medical Associates Commercial |
$1,083.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,011.50
|
| Rate for Payer: United Healthcare Commercial |
$1,300.50
|
|
|
CT Soft Tissue Neck w/ Contrast
|
Facility
OP
|
$1,445.00
|
|
|
Service Code
|
CPT 70491
|
| Hospital Charge Code |
1168232
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$722.21 |
| Max. Negotiated Rate |
$1,300.50 |
| Rate for Payer: Aetna of IA Commercial |
$1,300.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,300.50
|
| Rate for Payer: Aetna of IA Medicare |
$823.65
|
| Rate for Payer: Amerigroup Medicaid |
$729.29
|
| Rate for Payer: Amerigroup Medicare |
$729.72
|
| Rate for Payer: Cash Price |
$1,156.00
|
| Rate for Payer: Cash Price |
$1,156.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,083.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$722.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$722.21
|
| Rate for Payer: Medical Associates Commercial |
$1,083.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$722.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,011.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$733.34
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,083.75
|
| Rate for Payer: United Healthcare Commercial |
$1,300.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$852.55
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Soft Tissue Neck w/o Contrast
|
Facility
IP
|
$1,180.00
|
|
|
Service Code
|
CPT 70490
|
| Hospital Charge Code |
1168234
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$826.00 |
| Max. Negotiated Rate |
$1,062.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,062.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,062.00
|
| Rate for Payer: Cash Price |
$944.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$885.00
|
| Rate for Payer: Medical Associates Commercial |
$885.00
|
| Rate for Payer: Midlands Choice Commercial |
$826.00
|
| Rate for Payer: United Healthcare Commercial |
$1,062.00
|
|
|
CT Soft Tissue Neck w/o Contrast
|
Facility
OP
|
$1,180.00
|
|
|
Service Code
|
CPT 70490
|
| Hospital Charge Code |
1168234
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$480.50 |
| Max. Negotiated Rate |
$1,062.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,062.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,062.00
|
| Rate for Payer: Aetna of IA Medicare |
$672.60
|
| Rate for Payer: Amerigroup Medicaid |
$595.55
|
| Rate for Payer: Amerigroup Medicare |
$595.90
|
| Rate for Payer: Cash Price |
$944.00
|
| Rate for Payer: Cash Price |
$944.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$885.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$590.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$589.76
|
| Rate for Payer: Medical Associates Commercial |
$885.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$590.00
|
| Rate for Payer: Midlands Choice Commercial |
$826.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$598.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$885.00
|
| Rate for Payer: United Healthcare Commercial |
$1,062.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$696.20
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
|
CT Soft Tissue Neck w/ + w/o Contrast
|
Facility
IP
|
$1,656.00
|
|
|
Service Code
|
CPT 70492
|
| Hospital Charge Code |
1168230
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,159.20 |
| Max. Negotiated Rate |
$1,490.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,490.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,490.40
|
| Rate for Payer: Cash Price |
$1,324.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,242.00
|
| Rate for Payer: Medical Associates Commercial |
$1,242.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,159.20
|
| Rate for Payer: United Healthcare Commercial |
$1,490.40
|
|
|
CT Soft Tissue Neck w/ + w/o Contrast
|
Facility
OP
|
$1,656.00
|
|
|
Service Code
|
CPT 70492
|
| Hospital Charge Code |
1168230
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$827.67 |
| Max. Negotiated Rate |
$1,490.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,490.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,490.40
|
| Rate for Payer: Aetna of IA Medicare |
$943.92
|
| Rate for Payer: Amerigroup Medicaid |
$835.78
|
| Rate for Payer: Amerigroup Medicare |
$836.28
|
| Rate for Payer: Cash Price |
$1,324.80
|
| Rate for Payer: Cash Price |
$1,324.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,242.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$828.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$827.67
|
| Rate for Payer: Medical Associates Commercial |
$1,242.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$828.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,159.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$840.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,242.00
|
| Rate for Payer: United Healthcare Commercial |
$1,490.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$977.04
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Spine Cervical w/ Contrast
|
Facility
IP
|
$1,557.00
|
|
|
Service Code
|
CPT 72126
|
| Hospital Charge Code |
1168238
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,089.90 |
| Max. Negotiated Rate |
$1,401.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,401.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,401.30
|
| Rate for Payer: Cash Price |
$1,245.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,167.75
|
| Rate for Payer: Medical Associates Commercial |
$1,167.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,089.90
|
| Rate for Payer: United Healthcare Commercial |
$1,401.30
|
|
|
CT Spine Cervical w/ Contrast
|
Facility
OP
|
$1,557.00
|
|
|
Service Code
|
CPT 72126
|
| Hospital Charge Code |
1168238
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$778.19 |
| Max. Negotiated Rate |
$1,401.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,401.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,401.30
|
| Rate for Payer: Aetna of IA Medicare |
$887.49
|
| Rate for Payer: Amerigroup Medicaid |
$785.82
|
| Rate for Payer: Amerigroup Medicare |
$786.28
|
| Rate for Payer: Cash Price |
$1,245.60
|
| Rate for Payer: Cash Price |
$1,245.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,167.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$778.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$778.19
|
| Rate for Payer: Medical Associates Commercial |
$1,167.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$778.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,089.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$790.18
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,167.75
|
| Rate for Payer: United Healthcare Commercial |
$1,401.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$918.63
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Spine Cervical w/o Contrast
|
Facility
OP
|
$1,438.00
|
|
|
Service Code
|
CPT 72125
|
| Hospital Charge Code |
1168240
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.50 |
| Max. Negotiated Rate |
$1,294.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,294.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,294.20
|
| Rate for Payer: Aetna of IA Medicare |
$819.66
|
| Rate for Payer: Amerigroup Medicaid |
$725.76
|
| Rate for Payer: Amerigroup Medicare |
$726.19
|
| Rate for Payer: Cash Price |
$1,150.40
|
| Rate for Payer: Cash Price |
$1,150.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,078.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$719.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$718.71
|
| Rate for Payer: Medical Associates Commercial |
$1,078.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$719.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,006.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$729.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,078.50
|
| Rate for Payer: United Healthcare Commercial |
$1,294.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$848.42
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
|
CT Spine Cervical w/o Contrast
|
Facility
IP
|
$1,438.00
|
|
|
Service Code
|
CPT 72125
|
| Hospital Charge Code |
1168240
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,006.60 |
| Max. Negotiated Rate |
$1,294.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,294.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,294.20
|
| Rate for Payer: Cash Price |
$1,150.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,078.50
|
| Rate for Payer: Medical Associates Commercial |
$1,078.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,006.60
|
| Rate for Payer: United Healthcare Commercial |
$1,294.20
|
|
|
CT Spine Cervical w/ + w/o Contrast
|
Facility
IP
|
$1,809.00
|
|
|
Service Code
|
CPT 72127
|
| Hospital Charge Code |
1168236
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,266.30 |
| Max. Negotiated Rate |
$1,628.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,628.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,628.10
|
| Rate for Payer: Cash Price |
$1,447.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,356.75
|
| Rate for Payer: Medical Associates Commercial |
$1,356.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,266.30
|
| Rate for Payer: United Healthcare Commercial |
$1,628.10
|
|
|
CT Spine Cervical w/ + w/o Contrast
|
Facility
OP
|
$1,809.00
|
|
|
Service Code
|
CPT 72127
|
| Hospital Charge Code |
1168236
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$904.14 |
| Max. Negotiated Rate |
$1,628.10 |
| Rate for Payer: Aetna of IA Commercial |
$1,628.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,628.10
|
| Rate for Payer: Aetna of IA Medicare |
$1,031.13
|
| Rate for Payer: Amerigroup Medicaid |
$913.00
|
| Rate for Payer: Amerigroup Medicare |
$913.54
|
| Rate for Payer: Cash Price |
$1,447.20
|
| Rate for Payer: Cash Price |
$1,447.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,356.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$904.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$904.14
|
| Rate for Payer: Medical Associates Commercial |
$1,356.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$904.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,266.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$918.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,356.75
|
| Rate for Payer: United Healthcare Commercial |
$1,628.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,067.31
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Spine Lumbar w/ Contrast
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
CPT 72132
|
| Hospital Charge Code |
1168244
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,195.60 |
| Max. Negotiated Rate |
$1,537.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,537.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,537.20
|
| Rate for Payer: Cash Price |
$1,366.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,281.00
|
| Rate for Payer: Medical Associates Commercial |
$1,281.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,195.60
|
| Rate for Payer: United Healthcare Commercial |
$1,537.20
|
|
|
CT Spine Lumbar w/ Contrast
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
CPT 72132
|
| Hospital Charge Code |
1168244
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$853.66 |
| Max. Negotiated Rate |
$1,537.20 |
| Rate for Payer: Aetna of IA Commercial |
$1,537.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,537.20
|
| Rate for Payer: Aetna of IA Medicare |
$973.56
|
| Rate for Payer: Amerigroup Medicaid |
$862.03
|
| Rate for Payer: Amerigroup Medicare |
$862.54
|
| Rate for Payer: Cash Price |
$1,366.40
|
| Rate for Payer: Cash Price |
$1,366.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,281.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$854.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$853.66
|
| Rate for Payer: Medical Associates Commercial |
$1,281.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$854.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,195.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$866.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,281.00
|
| Rate for Payer: United Healthcare Commercial |
$1,537.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,007.72
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Spine Lumbar w/o Contrast
|
Facility
OP
|
$1,440.00
|
|
|
Service Code
|
CPT 72131
|
| Hospital Charge Code |
1168246
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.50 |
| Max. Negotiated Rate |
$1,296.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,296.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,296.00
|
| Rate for Payer: Aetna of IA Medicare |
$820.80
|
| Rate for Payer: Amerigroup Medicaid |
$726.77
|
| Rate for Payer: Amerigroup Medicare |
$727.20
|
| Rate for Payer: Cash Price |
$1,152.00
|
| Rate for Payer: Cash Price |
$1,152.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,080.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$720.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$719.71
|
| Rate for Payer: Medical Associates Commercial |
$1,080.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$720.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,008.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$730.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare Commercial |
$1,296.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$849.60
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
