|
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
|
|
|
CT Spine Lumbar w/ + w/o Contrast
|
Facility
IP
|
$1,809.00
|
|
|
Service Code
|
CPT 72133
|
| Hospital Charge Code |
1168242
|
|
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 Lumbar w/ + w/o Contrast
|
Facility
OP
|
$1,809.00
|
|
|
Service Code
|
CPT 72133
|
| Hospital Charge Code |
1168242
|
|
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 Thoracic w/ Contrast
|
Facility
IP
|
$1,708.00
|
|
|
Service Code
|
CPT 72129
|
| Hospital Charge Code |
1168250
|
|
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 Thoracic w/ Contrast
|
Facility
OP
|
$1,708.00
|
|
|
Service Code
|
CPT 72129
|
| Hospital Charge Code |
1168250
|
|
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 Thoracic w/o Contrast
|
Facility
IP
|
$1,426.00
|
|
|
Service Code
|
CPT 72128
|
| Hospital Charge Code |
1168252
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$998.20 |
| Max. Negotiated Rate |
$1,283.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,283.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,283.40
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,069.50
|
| Rate for Payer: Medical Associates Commercial |
$1,069.50
|
| Rate for Payer: Midlands Choice Commercial |
$998.20
|
| Rate for Payer: United Healthcare Commercial |
$1,283.40
|
|
|
CT Spine Thoracic w/o Contrast
|
Facility
OP
|
$1,426.00
|
|
|
Service Code
|
CPT 72128
|
| Hospital Charge Code |
1168252
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.50 |
| Max. Negotiated Rate |
$1,283.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,283.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,283.40
|
| Rate for Payer: Aetna of IA Medicare |
$812.82
|
| Rate for Payer: Amerigroup Medicaid |
$719.70
|
| Rate for Payer: Amerigroup Medicare |
$720.13
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,069.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$713.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$712.71
|
| Rate for Payer: Medical Associates Commercial |
$1,069.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$713.00
|
| Rate for Payer: Midlands Choice Commercial |
$998.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$723.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,069.50
|
| Rate for Payer: United Healthcare Commercial |
$1,283.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$841.34
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
|
CT Spine Thoracic w/ + w/o Contrast
|
Facility
OP
|
$1,809.00
|
|
|
Service Code
|
CPT 72130
|
| Hospital Charge Code |
1168248
|
|
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 Thoracic w/ + w/o Contrast
|
Facility
IP
|
$1,809.00
|
|
|
Service Code
|
CPT 72130
|
| Hospital Charge Code |
1168248
|
|
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 Tibia/Fibula w/ Contrast Left
|
Facility
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
1168297
|
|
Hospital Revenue Code
|
352
|
| 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
|
|
|
CT Tibia/Fibula w/ Contrast Left
|
Facility
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
1168297
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$717.71 |
| 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: Aetna of IA Medicare |
$818.52
|
| Rate for Payer: Amerigroup Medicaid |
$724.75
|
| Rate for Payer: Amerigroup Medicare |
$725.18
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,077.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$718.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$717.71
|
| Rate for Payer: Medical Associates Commercial |
$1,077.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$718.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,005.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$728.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,077.00
|
| Rate for Payer: United Healthcare Commercial |
$1,292.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$847.24
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Tibia/Fibula w/ Contrast Right
|
Facility
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
1168299
|
|
Hospital Revenue Code
|
352
|
| 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
|
|
|
CT Tibia/Fibula w/ Contrast Right
|
Facility
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701
|
| Hospital Charge Code |
1168299
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$717.71 |
| 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: Aetna of IA Medicare |
$818.52
|
| Rate for Payer: Amerigroup Medicaid |
$724.75
|
| Rate for Payer: Amerigroup Medicare |
$725.18
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,077.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$718.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$717.71
|
| Rate for Payer: Medical Associates Commercial |
$1,077.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$718.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,005.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$728.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,077.00
|
| Rate for Payer: United Healthcare Commercial |
$1,292.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$847.24
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Tibia/Fibula w/o Contrast Left
|
Facility
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700
|
| Hospital Charge Code |
1168303
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$784.70 |
| Max. Negotiated Rate |
$1,008.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,008.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,008.90
|
| Rate for Payer: Cash Price |
$896.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$840.75
|
| Rate for Payer: Medical Associates Commercial |
$840.75
|
| Rate for Payer: Midlands Choice Commercial |
$784.70
|
| Rate for Payer: United Healthcare Commercial |
$1,008.90
|
|
|
CT Tibia/Fibula w/o Contrast Left
|
Facility
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700
|
| Hospital Charge Code |
1168303
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.50 |
| Max. Negotiated Rate |
$1,008.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,008.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,008.90
|
| Rate for Payer: Aetna of IA Medicare |
$638.97
|
| Rate for Payer: Amerigroup Medicaid |
$565.77
|
| Rate for Payer: Amerigroup Medicare |
$566.10
|
| Rate for Payer: Cash Price |
$896.80
|
| Rate for Payer: Cash Price |
$896.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$840.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$560.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$560.28
|
| Rate for Payer: Medical Associates Commercial |
$840.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$560.50
|
| Rate for Payer: Midlands Choice Commercial |
$784.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$568.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$840.75
|
| Rate for Payer: United Healthcare Commercial |
$1,008.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$661.39
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
|
CT Tibia/Fibula w/o Contrast Right
|
Facility
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700
|
| Hospital Charge Code |
1168305
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$480.50 |
| Max. Negotiated Rate |
$1,008.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,008.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,008.90
|
| Rate for Payer: Aetna of IA Medicare |
$638.97
|
| Rate for Payer: Amerigroup Medicaid |
$565.77
|
| Rate for Payer: Amerigroup Medicare |
$566.10
|
| Rate for Payer: Cash Price |
$896.80
|
| Rate for Payer: Cash Price |
$896.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$840.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$560.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$560.28
|
| Rate for Payer: Medical Associates Commercial |
$840.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$560.50
|
| Rate for Payer: Midlands Choice Commercial |
$784.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$568.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$840.75
|
| Rate for Payer: United Healthcare Commercial |
$1,008.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$661.39
|
| Rate for Payer: Wellmark IA HMO |
$480.50
|
| Rate for Payer: Wellmark IA PPO |
$528.55
|
|
|
CT Tibia/Fibula w/o Contrast Right
|
Facility
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700
|
| Hospital Charge Code |
1168305
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$784.70 |
| Max. Negotiated Rate |
$1,008.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,008.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,008.90
|
| Rate for Payer: Cash Price |
$896.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$840.75
|
| Rate for Payer: Medical Associates Commercial |
$840.75
|
| Rate for Payer: Midlands Choice Commercial |
$784.70
|
| Rate for Payer: United Healthcare Commercial |
$1,008.90
|
|
|
CT Tibia/Fibula w/ + w/o Contrast Left
|
Facility
IP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
1168291
|
|
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 Tibia/Fibula w/ + w/o Contrast Left
|
Facility
OP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
1168291
|
|
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: 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 Tibia/Fibula w/ + w/o Contrast Right
|
Facility
OP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
1168293
|
|
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: 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 Tibia/Fibula w/ + w/o Contrast Right
|
Facility
IP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
1168293
|
|
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 Upper Extremity w/ Contrast Left
|
Facility
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
1168311
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$717.71 |
| 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: Aetna of IA Medicare |
$818.52
|
| Rate for Payer: Amerigroup Medicaid |
$724.75
|
| Rate for Payer: Amerigroup Medicare |
$725.18
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,077.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$718.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$717.71
|
| Rate for Payer: Medical Associates Commercial |
$1,077.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$718.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,005.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$728.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,077.00
|
| Rate for Payer: United Healthcare Commercial |
$1,292.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$847.24
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
|
CT Upper Extremity w/ Contrast Left
|
Facility
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
1168311
|
|
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
|
|
|
CT Upper Extremity w/ Contrast Right
|
Facility
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
1168313
|
|
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
|
|
|
CT Upper Extremity w/ Contrast Right
|
Facility
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201
|
| Hospital Charge Code |
1168313
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$717.71 |
| 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: Aetna of IA Medicare |
$818.52
|
| Rate for Payer: Amerigroup Medicaid |
$724.75
|
| Rate for Payer: Amerigroup Medicare |
$725.18
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,077.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$718.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$717.71
|
| Rate for Payer: Medical Associates Commercial |
$1,077.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$718.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,005.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$728.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,077.00
|
| Rate for Payer: United Healthcare Commercial |
$1,292.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$847.24
|
| Rate for Payer: Wellmark IA HMO |
$1,042.22
|
| Rate for Payer: Wellmark IA PPO |
$1,146.44
|
|
