|
CT Angiography Abdomen
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
CPT 74175
|
| Hospital Charge Code |
1167853
|
|
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 Angiography Chest w/ Contrast
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
CPT 71275
|
| Hospital Charge Code |
7960796
|
|
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 Angiography Chest w/ Contrast
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
CPT 71275
|
| Hospital Charge Code |
7960796
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$544.50 |
| 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: Aetna of IA Medicare |
$689.70
|
| Rate for Payer: Amerigroup Medicaid |
$697.93
|
| Rate for Payer: Amerigroup Medicare |
$549.94
|
| 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 |
$544.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$691.15
|
| Rate for Payer: Medical Associates Commercial |
$907.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$544.50
|
| Rate for Payer: Midlands Choice Commercial |
$847.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$701.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$626.18
|
| Rate for Payer: United Healthcare Commercial |
$1,089.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$713.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$684.19
|
| Rate for Payer: Wellmark IA PPO |
$753.67
|
|
|
CT Angiography Head w/ Contrast
|
Facility
|
IP
|
$1,445.00
|
|
|
Service Code
|
CPT 70496
|
| Hospital Charge Code |
7960805
|
|
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 Angiography Head w/ Contrast
|
Facility
|
OP
|
$1,445.00
|
|
|
Service Code
|
CPT 70496
|
| Hospital Charge Code |
7960805
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$650.25 |
| 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 |
$833.48
|
| Rate for Payer: Amerigroup Medicare |
$656.75
|
| 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 |
$650.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$825.38
|
| Rate for Payer: Medical Associates Commercial |
$1,083.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$650.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,011.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$837.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$747.79
|
| Rate for Payer: United Healthcare Commercial |
$1,300.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$852.55
|
| Rate for Payer: Wellmark IA HMO WHPI |
$684.19
|
| Rate for Payer: Wellmark IA PPO |
$753.67
|
|
|
CT Angiography Neck w/ Contrast
|
Facility
|
IP
|
$1,445.00
|
|
|
Service Code
|
CPT 70498
|
| Hospital Charge Code |
7960808
|
|
Hospital Revenue Code
|
352
|
| 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 Angiography Neck w/ Contrast
|
Facility
|
OP
|
$1,445.00
|
|
|
Service Code
|
CPT 70498
|
| Hospital Charge Code |
7960808
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$650.25 |
| 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 |
$833.48
|
| Rate for Payer: Amerigroup Medicare |
$656.75
|
| 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 |
$650.25
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$825.38
|
| Rate for Payer: Medical Associates Commercial |
$1,083.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$650.25
|
| Rate for Payer: Midlands Choice Commercial |
$1,011.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$837.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$747.79
|
| Rate for Payer: United Healthcare Commercial |
$1,300.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$852.55
|
| Rate for Payer: Wellmark IA HMO WHPI |
$684.19
|
| Rate for Payer: Wellmark IA PPO |
$753.67
|
|
|
CT Angiography of Abdomen + Pelvis
|
Facility
|
IP
|
$2,420.00
|
|
|
Service Code
|
CPT 74174
|
| Hospital Charge Code |
2410305
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,694.00 |
| Max. Negotiated Rate |
$2,178.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,178.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,178.00
|
| Rate for Payer: Cash Price |
$1,936.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,815.00
|
| Rate for Payer: Medical Associates Commercial |
$1,815.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,694.00
|
| Rate for Payer: United Healthcare Commercial |
$2,178.00
|
|
|
CT Angiography of Abdomen + Pelvis
|
Facility
|
OP
|
$2,420.00
|
|
|
Service Code
|
CPT 74174
|
| Hospital Charge Code |
2410305
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$684.19 |
| Max. Negotiated Rate |
$2,178.00 |
| Rate for Payer: Aetna of IA Commercial |
$2,178.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$2,178.00
|
| Rate for Payer: Aetna of IA Medicare |
$1,379.40
|
| Rate for Payer: Amerigroup Medicaid |
$1,395.86
|
| Rate for Payer: Amerigroup Medicare |
$1,099.89
|
| Rate for Payer: Cash Price |
$1,936.00
|
| Rate for Payer: Cash Price |
$1,936.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,815.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,089.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,382.30
|
| Rate for Payer: Medical Associates Commercial |
$1,815.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,089.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,694.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,402.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,252.35
|
| Rate for Payer: United Healthcare Commercial |
$2,178.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,427.80
|
| Rate for Payer: Wellmark IA HMO WHPI |
$684.19
|
| Rate for Payer: Wellmark IA PPO |
$753.67
|
|
|
CT Angiography Pelvis w/ Contrast
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
CPT 72191
|
| Hospital Charge Code |
7960811
|
|
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 Angiography Pelvis w/ Contrast
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
CPT 72191
|
| Hospital Charge Code |
7960811
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$544.50 |
| 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: Aetna of IA Medicare |
$689.70
|
| Rate for Payer: Amerigroup Medicaid |
$697.93
|
| Rate for Payer: Amerigroup Medicare |
$549.94
|
| 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 |
$544.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$691.15
|
| Rate for Payer: Medical Associates Commercial |
$907.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$544.50
|
| Rate for Payer: Midlands Choice Commercial |
$847.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$701.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$626.18
|
| Rate for Payer: United Healthcare Commercial |
$1,089.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$713.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$684.19
|
| Rate for Payer: Wellmark IA PPO |
$753.67
|
|
|
CT Angiography Upper Extremity Left
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
CPT 73206 LT
|
| Hospital Charge Code |
1167885
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$544.50 |
| 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: Aetna of IA Medicare |
$689.70
|
| Rate for Payer: Amerigroup Medicaid |
$697.93
|
| Rate for Payer: Amerigroup Medicare |
$549.94
|
| 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 |
$544.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$691.15
|
| Rate for Payer: Medical Associates Commercial |
$907.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$544.50
|
| Rate for Payer: Midlands Choice Commercial |
$847.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$701.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$626.18
|
| Rate for Payer: United Healthcare Commercial |
$1,089.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$713.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$684.19
|
| Rate for Payer: Wellmark IA PPO |
$753.67
|
|
|
CT Angiography Upper Extremity Left
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
CPT 73206 LT
|
| Hospital Charge Code |
1167885
|
|
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 Angiography Upper Extremity Right
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
CPT 73206 RT
|
| Hospital Charge Code |
1167887
|
|
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 Angiography Upper Extremity Right
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
CPT 73206 RT
|
| Hospital Charge Code |
1167887
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$544.50 |
| 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: Aetna of IA Medicare |
$689.70
|
| Rate for Payer: Amerigroup Medicaid |
$697.93
|
| Rate for Payer: Amerigroup Medicare |
$549.94
|
| 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 |
$544.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$691.15
|
| Rate for Payer: Medical Associates Commercial |
$907.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$544.50
|
| Rate for Payer: Midlands Choice Commercial |
$847.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$701.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$626.18
|
| Rate for Payer: United Healthcare Commercial |
$1,089.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$713.90
|
| Rate for Payer: Wellmark IA HMO WHPI |
$684.19
|
| Rate for Payer: Wellmark IA PPO |
$753.67
|
|
|
CT Ankle w/ Contrast Left
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 LT
|
| Hospital Charge Code |
1167897
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$646.20 |
| 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: Aetna of IA Medicare |
$818.52
|
| Rate for Payer: Amerigroup Medicaid |
$828.28
|
| Rate for Payer: Amerigroup Medicare |
$652.66
|
| 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 |
$646.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$820.24
|
| Rate for Payer: Medical Associates Commercial |
$1,077.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$646.20
|
| Rate for Payer: Midlands Choice Commercial |
$1,005.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$832.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$743.13
|
| Rate for Payer: United Healthcare Commercial |
$1,292.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$847.24
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT Ankle w/ Contrast Left
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 LT
|
| Hospital Charge Code |
1167897
|
|
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 Ankle w/ Contrast Right
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 RT
|
| Hospital Charge Code |
1167899
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$646.20 |
| 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: Aetna of IA Medicare |
$818.52
|
| Rate for Payer: Amerigroup Medicaid |
$828.28
|
| Rate for Payer: Amerigroup Medicare |
$652.66
|
| 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 |
$646.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$820.24
|
| Rate for Payer: Medical Associates Commercial |
$1,077.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$646.20
|
| Rate for Payer: Midlands Choice Commercial |
$1,005.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$832.31
|
| Rate for Payer: Partners Health Alliance Commercial |
$743.13
|
| Rate for Payer: United Healthcare Commercial |
$1,292.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$847.24
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT Ankle w/ Contrast Right
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 RT
|
| Hospital Charge Code |
1167899
|
|
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 Ankle w/o Contrast Left
|
Facility
|
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 LT
|
| Hospital Charge Code |
1167903
|
|
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 Ankle w/o Contrast Left
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 LT
|
| Hospital Charge Code |
1167903
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$312.67 |
| 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 |
$646.59
|
| Rate for Payer: Amerigroup Medicare |
$509.49
|
| 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 |
$504.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$640.32
|
| Rate for Payer: Medical Associates Commercial |
$840.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$504.45
|
| Rate for Payer: Midlands Choice Commercial |
$784.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$649.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$580.12
|
| Rate for Payer: United Healthcare Commercial |
$1,008.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$661.39
|
| Rate for Payer: Wellmark IA HMO WHPI |
$312.67
|
| Rate for Payer: Wellmark IA PPO |
$344.42
|
|
|
CT Ankle w/o Contrast Right
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
1167905
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$312.67 |
| 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 |
$646.59
|
| Rate for Payer: Amerigroup Medicare |
$509.49
|
| 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 |
$504.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$640.32
|
| Rate for Payer: Medical Associates Commercial |
$840.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$504.45
|
| Rate for Payer: Midlands Choice Commercial |
$784.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$649.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$580.12
|
| Rate for Payer: United Healthcare Commercial |
$1,008.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$661.39
|
| Rate for Payer: Wellmark IA HMO WHPI |
$312.67
|
| Rate for Payer: Wellmark IA PPO |
$344.42
|
|
|
CT Ankle w/o Contrast Right
|
Facility
|
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
1167905
|
|
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 Ankle w/ + w/o Contrast Left
|
Facility
|
OP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 LT
|
| Hospital Charge Code |
1167891
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$716.40 |
| 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: Aetna of IA Medicare |
$907.44
|
| Rate for Payer: Amerigroup Medicaid |
$918.27
|
| Rate for Payer: Amerigroup Medicare |
$723.56
|
| 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 |
$716.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$909.35
|
| Rate for Payer: Medical Associates Commercial |
$1,194.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$716.40
|
| Rate for Payer: Midlands Choice Commercial |
$1,114.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$922.72
|
| Rate for Payer: Partners Health Alliance Commercial |
$823.86
|
| Rate for Payer: United Healthcare Commercial |
$1,432.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$939.28
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT Ankle w/ + w/o Contrast Left
|
Facility
|
IP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 LT
|
| Hospital Charge Code |
1167891
|
|
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
|
|
