|
CT IAC w/ Contrast
|
Facility
|
OP
|
$1,540.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
1168140
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$693.00 |
| 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: Aetna of IA Medicare |
$877.80
|
| Rate for Payer: Amerigroup Medicaid |
$888.27
|
| Rate for Payer: Amerigroup Medicare |
$699.93
|
| 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 |
$693.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$879.65
|
| Rate for Payer: Medical Associates Commercial |
$1,155.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$693.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,078.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$892.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$796.95
|
| Rate for Payer: United Healthcare Commercial |
$1,386.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$908.60
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT IAC w/ Contrast
|
Facility
|
IP
|
$1,540.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
1168140
|
|
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 IAC w/o Contrast
|
Facility
|
IP
|
$909.00
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
1168142
|
|
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 IAC w/o Contrast
|
Facility
|
OP
|
$909.00
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
1168142
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$312.67 |
| 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 |
$524.31
|
| Rate for Payer: Amerigroup Medicare |
$413.14
|
| 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 |
$409.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$519.22
|
| Rate for Payer: Medical Associates Commercial |
$681.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$409.05
|
| Rate for Payer: Midlands Choice Commercial |
$636.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$526.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$470.41
|
| Rate for Payer: United Healthcare Commercial |
$818.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$536.31
|
| Rate for Payer: Wellmark IA HMO WHPI |
$312.67
|
| Rate for Payer: Wellmark IA PPO |
$344.42
|
|
|
CT IAC w/ + w/o Contrast
|
Facility
|
OP
|
$1,623.00
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
1168138
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$730.35 |
| 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 |
$936.15
|
| Rate for Payer: Amerigroup Medicare |
$737.65
|
| 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 |
$730.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$927.06
|
| Rate for Payer: Medical Associates Commercial |
$1,217.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$730.35
|
| Rate for Payer: Midlands Choice Commercial |
$1,136.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$940.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$839.90
|
| Rate for Payer: United Healthcare Commercial |
$1,460.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$957.57
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT IAC w/ + w/o Contrast
|
Facility
|
IP
|
$1,623.00
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
1168138
|
|
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 Knee w/ Contrast Left
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 LT
|
| Hospital Charge Code |
1168152
|
|
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 Knee w/ Contrast Left
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 LT
|
| Hospital Charge Code |
1168152
|
|
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 Knee w/ Contrast Right
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 RT
|
| Hospital Charge Code |
1168154
|
|
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 Knee w/ Contrast Right
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 RT
|
| Hospital Charge Code |
1168154
|
|
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 Knee w/o Contrast Left
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 LT
|
| Hospital Charge Code |
1168158
|
|
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 Knee w/o Contrast Left
|
Facility
|
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 LT
|
| Hospital Charge Code |
1168158
|
|
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 Knee w/o Contrast Right
|
Facility
|
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
1168160
|
|
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 Knee w/o Contrast Right
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
1168160
|
|
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 Knee w/ + w/o Contrast Left
|
Facility
|
IP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 LT
|
| Hospital Charge Code |
1168146
|
|
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 Knee w/ + w/o Contrast Left
|
Facility
|
OP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 LT
|
| Hospital Charge Code |
1168146
|
|
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 Knee w/ + w/o Contrast Right
|
Facility
|
OP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 RT
|
| Hospital Charge Code |
1168148
|
|
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 Knee w/ + w/o Contrast Right
|
Facility
|
IP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 RT
|
| Hospital Charge Code |
1168148
|
|
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 Limited or Localized F/U Study
|
Facility
|
IP
|
$627.00
|
|
|
Service Code
|
CPT 76380
|
| Hospital Charge Code |
1168162
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$438.90 |
| Max. Negotiated Rate |
$564.30 |
| Rate for Payer: Aetna of IA Commercial |
$564.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$564.30
|
| Rate for Payer: Cash Price |
$501.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$470.25
|
| Rate for Payer: Medical Associates Commercial |
$470.25
|
| Rate for Payer: Midlands Choice Commercial |
$438.90
|
| Rate for Payer: United Healthcare Commercial |
$564.30
|
|
|
CT Limited or Localized F/U Study
|
Facility
|
OP
|
$627.00
|
|
|
Service Code
|
CPT 76380
|
| Hospital Charge Code |
1168162
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$282.15 |
| Max. Negotiated Rate |
$564.30 |
| Rate for Payer: Aetna of IA Commercial |
$564.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$564.30
|
| Rate for Payer: Aetna of IA Medicare |
$357.39
|
| Rate for Payer: Amerigroup Medicaid |
$361.65
|
| Rate for Payer: Amerigroup Medicare |
$284.97
|
| Rate for Payer: Cash Price |
$501.60
|
| Rate for Payer: Cash Price |
$501.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$470.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$282.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$358.14
|
| Rate for Payer: Medical Associates Commercial |
$470.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$282.15
|
| Rate for Payer: Midlands Choice Commercial |
$438.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$363.41
|
| Rate for Payer: Partners Health Alliance Commercial |
$324.47
|
| Rate for Payer: United Healthcare Commercial |
$564.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$369.93
|
| Rate for Payer: Wellmark IA HMO WHPI |
$312.67
|
| Rate for Payer: Wellmark IA PPO |
$344.42
|
|
|
CT Lower Extremity w/ Contrast Left
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 LT
|
| Hospital Charge Code |
1168166
|
|
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 Lower Extremity w/ Contrast Left
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 LT
|
| Hospital Charge Code |
1168166
|
|
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 Lower Extremity w/ Contrast Right
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 RT
|
| Hospital Charge Code |
1168168
|
|
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 Lower Extremity w/ Contrast Right
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73701 RT
|
| Hospital Charge Code |
1168168
|
|
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 Lower Extremity w/o Contrast Left
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 LT
|
| Hospital Charge Code |
1168178
|
|
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
|
|
