|
CT Lower Extremity w/+w/o Contrast Right
|
Facility
|
OP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
1168174
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$795.68 |
| Max. Negotiated Rate |
$1,432.80 |
| Rate for Payer: Aetna of IA Commercial |
$1,432.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,432.80
|
| Rate for Payer: Aetna of IA Medicare |
$907.44
|
| Rate for Payer: Amerigroup Medicaid |
$803.48
|
| Rate for Payer: Amerigroup Medicare |
$803.96
|
| Rate for Payer: Cash Price |
$1,273.60
|
| Rate for Payer: Cash Price |
$1,273.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,194.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$796.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$795.68
|
| Rate for Payer: Medical Associates Commercial |
$1,194.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$796.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,114.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$807.94
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$807.46
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,194.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,194.00
|
| Rate for Payer: United Healthcare Commercial |
$1,432.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$939.28
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Lower Extremity w/+w/o Contrast Right
|
Facility
|
IP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
1168174
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,114.40 |
| Max. Negotiated Rate |
$1,432.80 |
| Rate for Payer: Aetna of IA Commercial |
$1,432.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,432.80
|
| Rate for Payer: Cash Price |
$1,273.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,194.00
|
| Rate for Payer: Medical Associates Commercial |
$1,194.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,114.40
|
| Rate for Payer: United Healthcare Commercial |
$1,432.80
|
|
|
CT LUNG LOW CA SCREENING
|
Facility
|
OP
|
$395.00
|
|
|
Service Code
|
CPT 71271
|
| Hospital Charge Code |
8340808
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$197.42 |
| Max. Negotiated Rate |
$355.50 |
| Rate for Payer: Aetna of IA Commercial |
$355.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$355.50
|
| Rate for Payer: Aetna of IA Medicare |
$225.15
|
| Rate for Payer: Amerigroup Medicaid |
$199.36
|
| Rate for Payer: Amerigroup Medicare |
$199.48
|
| Rate for Payer: Cash Price |
$316.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$296.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$197.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$197.42
|
| Rate for Payer: Medical Associates Commercial |
$296.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$197.50
|
| Rate for Payer: Midlands Choice Commercial |
$276.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$200.46
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$200.34
|
| Rate for Payer: Oscar Health of IA Commercial |
$296.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$296.25
|
| Rate for Payer: United Healthcare Commercial |
$355.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$233.05
|
|
|
CT LUNG LOW CA SCREENING
|
Facility
|
IP
|
$395.00
|
|
|
Service Code
|
CPT 71271
|
| Hospital Charge Code |
8340808
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$276.50 |
| Max. Negotiated Rate |
$355.50 |
| Rate for Payer: Aetna of IA Commercial |
$355.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$355.50
|
| Rate for Payer: Cash Price |
$316.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$296.25
|
| Rate for Payer: Medical Associates Commercial |
$296.25
|
| Rate for Payer: Midlands Choice Commercial |
$276.50
|
| Rate for Payer: United Healthcare Commercial |
$355.50
|
|
|
CT Maxillofacial w/ Contrast
|
Facility
|
OP
|
$1,540.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
1168184
|
|
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: Molina Healthcare Managed Medicare |
$781.09
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,155.00
|
| 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 Maxillofacial w/ Contrast
|
Facility
|
IP
|
$1,540.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
1168184
|
|
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 Maxillofacial w/o Contrast
|
Facility
|
OP
|
$1,180.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
1168186
|
|
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: Molina Healthcare Managed Medicare |
$598.50
|
| Rate for Payer: Oscar Health of IA Commercial |
$885.00
|
| 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 Maxillofacial w/o Contrast
|
Facility
|
IP
|
$1,180.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
1168186
|
|
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 Maxillofacial w/ + w/o Contrast
|
Facility
|
OP
|
$1,503.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
1168182
|
|
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: Molina Healthcare Managed Medicare |
$762.32
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,127.25
|
| 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 Maxillofacial w/ + w/o Contrast
|
Facility
|
IP
|
$1,503.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
1168182
|
|
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 Orbit Sella etc. w/ Contrast
|
Facility
|
IP
|
$1,540.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
1168190
|
|
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 Orbit Sella etc. w/ Contrast
|
Facility
|
OP
|
$1,540.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
1168190
|
|
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: Molina Healthcare Managed Medicare |
$781.09
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,155.00
|
| 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 Orbit Sella etc. w/o Contrast
|
Facility
|
OP
|
$909.00
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
1168192
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$454.32 |
| Max. Negotiated Rate |
$818.10 |
| Rate for Payer: Aetna of IA Commercial |
$818.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$818.10
|
| Rate for Payer: Aetna of IA Medicare |
$518.13
|
| Rate for Payer: Amerigroup Medicaid |
$458.77
|
| Rate for Payer: Amerigroup Medicare |
$459.04
|
| Rate for Payer: Cash Price |
$727.20
|
| Rate for Payer: Cash Price |
$727.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$681.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$454.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$454.32
|
| Rate for Payer: Medical Associates Commercial |
$681.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$454.50
|
| Rate for Payer: Midlands Choice Commercial |
$636.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$461.32
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$461.04
|
| Rate for Payer: Oscar Health of IA Commercial |
$681.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$681.75
|
| Rate for Payer: United Healthcare Commercial |
$818.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$536.31
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
|
CT Orbit Sella etc. w/o Contrast
|
Facility
|
IP
|
$909.00
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
1168192
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$636.30 |
| Max. Negotiated Rate |
$818.10 |
| Rate for Payer: Aetna of IA Commercial |
$818.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$818.10
|
| Rate for Payer: Cash Price |
$727.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$681.75
|
| Rate for Payer: Medical Associates Commercial |
$681.75
|
| Rate for Payer: Midlands Choice Commercial |
$636.30
|
| Rate for Payer: United Healthcare Commercial |
$818.10
|
|
|
CT Orbit Sella etc. w/ + w/o Contrast
|
Facility
|
IP
|
$1,623.00
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
1168188
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,136.10 |
| Max. Negotiated Rate |
$1,460.70 |
| Rate for Payer: Aetna of IA Commercial |
$1,460.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,460.70
|
| Rate for Payer: Cash Price |
$1,298.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,217.25
|
| Rate for Payer: Medical Associates Commercial |
$1,217.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,136.10
|
| Rate for Payer: United Healthcare Commercial |
$1,460.70
|
|
|
CT Orbit Sella etc. w/ + w/o Contrast
|
Facility
|
OP
|
$1,623.00
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
1168188
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$811.18 |
| Max. Negotiated Rate |
$1,460.70 |
| Rate for Payer: Aetna of IA Commercial |
$1,460.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,460.70
|
| Rate for Payer: Aetna of IA Medicare |
$925.11
|
| Rate for Payer: Amerigroup Medicaid |
$819.13
|
| Rate for Payer: Amerigroup Medicare |
$819.62
|
| Rate for Payer: Cash Price |
$1,298.40
|
| Rate for Payer: Cash Price |
$1,298.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,217.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$811.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$811.18
|
| Rate for Payer: Medical Associates Commercial |
$1,217.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$811.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,136.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$823.67
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$823.19
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,217.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,217.25
|
| Rate for Payer: United Healthcare Commercial |
$1,460.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$957.57
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
1168196
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$604.76 |
| Max. Negotiated Rate |
$1,146.44 |
| Rate for Payer: Aetna of IA Commercial |
$1,089.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,089.00
|
| Rate for Payer: Aetna of IA Medicare |
$689.70
|
| Rate for Payer: Amerigroup Medicaid |
$610.69
|
| Rate for Payer: Amerigroup Medicare |
$611.05
|
| Rate for Payer: Cash Price |
$968.00
|
| Rate for Payer: Cash Price |
$968.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$907.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$605.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$604.76
|
| Rate for Payer: Medical Associates Commercial |
$907.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$605.00
|
| Rate for Payer: Midlands Choice Commercial |
$847.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$614.08
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$613.71
|
| Rate for Payer: Oscar Health of IA Commercial |
$907.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$907.50
|
| Rate for Payer: United Healthcare Commercial |
$1,089.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$713.90
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
1168196
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$847.00 |
| Max. Negotiated Rate |
$1,089.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,089.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,089.00
|
| Rate for Payer: Cash Price |
$968.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$907.50
|
| Rate for Payer: Medical Associates Commercial |
$907.50
|
| Rate for Payer: Midlands Choice Commercial |
$847.00
|
| Rate for Payer: United Healthcare Commercial |
$1,089.00
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
IP
|
$1,146.00
|
|
|
Service Code
|
CPT 72192
|
| Hospital Charge Code |
1168198
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$802.20 |
| Max. Negotiated Rate |
$1,031.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,031.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,031.40
|
| Rate for Payer: Cash Price |
$916.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$859.50
|
| Rate for Payer: Medical Associates Commercial |
$859.50
|
| Rate for Payer: Midlands Choice Commercial |
$802.20
|
| Rate for Payer: United Healthcare Commercial |
$1,031.40
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
OP
|
$1,146.00
|
|
|
Service Code
|
CPT 72192
|
| Hospital Charge Code |
1168198
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.50 |
| Max. Negotiated Rate |
$1,031.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,031.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,031.40
|
| Rate for Payer: Aetna of IA Medicare |
$653.22
|
| Rate for Payer: Amerigroup Medicaid |
$578.39
|
| Rate for Payer: Amerigroup Medicare |
$578.73
|
| Rate for Payer: Cash Price |
$916.80
|
| Rate for Payer: Cash Price |
$916.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$859.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$573.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$572.77
|
| Rate for Payer: Medical Associates Commercial |
$859.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$573.00
|
| Rate for Payer: Midlands Choice Commercial |
$802.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$581.60
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$581.25
|
| Rate for Payer: Oscar Health of IA Commercial |
$859.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$859.50
|
| Rate for Payer: United Healthcare Commercial |
$1,031.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$676.14
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
|
CT Pelvis w/ + w/o Contrast
|
Facility
|
OP
|
$1,672.00
|
|
|
Service Code
|
CPT 72194
|
| Hospital Charge Code |
1168194
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$835.67 |
| Max. Negotiated Rate |
$1,504.80 |
| Rate for Payer: Aetna of IA Commercial |
$1,504.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,504.80
|
| Rate for Payer: Aetna of IA Medicare |
$953.04
|
| Rate for Payer: Amerigroup Medicaid |
$843.86
|
| Rate for Payer: Amerigroup Medicare |
$844.36
|
| Rate for Payer: Cash Price |
$1,337.60
|
| Rate for Payer: Cash Price |
$1,337.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,254.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$836.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$835.67
|
| Rate for Payer: Medical Associates Commercial |
$1,254.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$836.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,170.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$848.54
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$848.04
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,254.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,254.00
|
| Rate for Payer: United Healthcare Commercial |
$1,504.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$986.48
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Pelvis w/ + w/o Contrast
|
Facility
|
IP
|
$1,672.00
|
|
|
Service Code
|
CPT 72194
|
| Hospital Charge Code |
1168194
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,170.40 |
| Max. Negotiated Rate |
$1,504.80 |
| Rate for Payer: Aetna of IA Commercial |
$1,504.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,504.80
|
| Rate for Payer: Cash Price |
$1,337.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,254.00
|
| Rate for Payer: Medical Associates Commercial |
$1,254.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,170.40
|
| Rate for Payer: United Healthcare Commercial |
$1,504.80
|
|
|
C. trach N. gonorrhea DNA DMCL
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
CPT 87491
|
| Hospital Charge Code |
8037504
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$68.82 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna of IA Commercial |
$127.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.80
|
| Rate for Payer: Aetna of IA Medicare |
$80.94
|
| Rate for Payer: Amerigroup Medicaid |
$71.67
|
| Rate for Payer: Amerigroup Medicare |
$71.71
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$71.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$70.97
|
| Rate for Payer: Medical Associates Commercial |
$106.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$71.00
|
| Rate for Payer: Midlands Choice Commercial |
$99.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$72.06
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$72.02
|
| Rate for Payer: Oscar Health of IA Commercial |
$106.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$106.50
|
| Rate for Payer: United Healthcare Commercial |
$127.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$83.78
|
| Rate for Payer: Wellmark IA HMO |
$68.82
|
| Rate for Payer: Wellmark IA PPO |
$75.70
|
|
|
C. trach N. gonorrhea DNA DMCL
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
CPT 87491
|
| Hospital Charge Code |
8037504
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna of IA Commercial |
$127.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.80
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.50
|
| Rate for Payer: Medical Associates Commercial |
$106.50
|
| Rate for Payer: Midlands Choice Commercial |
$99.40
|
| Rate for Payer: United Healthcare Commercial |
$127.80
|
|
|
CT Shoulder w/ Contrast Left
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
1168214
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,005.20 |
| Max. Negotiated Rate |
$1,292.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,292.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,292.40
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,077.00
|
| Rate for Payer: Medical Associates Commercial |
$1,077.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,005.20
|
| Rate for Payer: United Healthcare Commercial |
$1,292.40
|
|
