|
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
|
|
|
CT Lower Extremity w/o Contrast Right
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
1168180
|
|
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 Lower Extremity w/o Contrast Right
|
Facility
|
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73700 RT
|
| Hospital Charge Code |
1168180
|
|
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 Lower Extremity w/+w/o Contrast Left
|
Facility
|
OP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 LT
|
| Hospital Charge Code |
1168172
|
|
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 Lower Extremity w/+w/o Contrast Left
|
Facility
|
IP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 LT
|
| Hospital Charge Code |
1168172
|
|
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 Lower Extremity w/+w/o Contrast Right
|
Facility
|
IP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 RT
|
| 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 Lower Extremity w/+w/o Contrast Right
|
Facility
|
OP
|
$1,592.00
|
|
|
Service Code
|
CPT 73702 RT
|
| Hospital Charge Code |
1168174
|
|
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 LUNG LOW CA SCREENING
|
Facility
|
OP
|
$395.00
|
|
|
Service Code
|
CPT 71271
|
| Hospital Charge Code |
8340808
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$177.75 |
| 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 |
$227.84
|
| Rate for Payer: Amerigroup Medicare |
$179.53
|
| Rate for Payer: Cash Price |
$316.00
|
| 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 |
$177.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$225.62
|
| Rate for Payer: Medical Associates Commercial |
$296.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$177.75
|
| Rate for Payer: Midlands Choice Commercial |
$276.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$228.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$204.41
|
| Rate for Payer: United Healthcare Commercial |
$355.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$233.05
|
| Rate for Payer: Wellmark IA HMO WHPI |
$312.67
|
| Rate for Payer: Wellmark IA PPO |
$344.42
|
|
|
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
|
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/ Contrast
|
Facility
|
OP
|
$1,540.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
1168184
|
|
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 Maxillofacial w/o Contrast
|
Facility
|
OP
|
$1,180.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
1168186
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$312.67 |
| 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 |
$680.62
|
| Rate for Payer: Amerigroup Medicare |
$536.31
|
| 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 |
$531.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$674.02
|
| Rate for Payer: Medical Associates Commercial |
$885.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$531.00
|
| Rate for Payer: Midlands Choice Commercial |
$826.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$683.93
|
| Rate for Payer: Partners Health Alliance Commercial |
$610.65
|
| Rate for Payer: United Healthcare Commercial |
$1,062.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$696.20
|
| Rate for Payer: Wellmark IA HMO WHPI |
$312.67
|
| Rate for Payer: Wellmark IA PPO |
$344.42
|
|
|
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 |
$676.35 |
| 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 |
$866.93
|
| Rate for Payer: Amerigroup Medicare |
$683.11
|
| 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 |
$676.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$858.51
|
| Rate for Payer: Medical Associates Commercial |
$1,127.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$676.35
|
| Rate for Payer: Midlands Choice Commercial |
$1,052.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$871.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$777.80
|
| Rate for Payer: United Healthcare Commercial |
$1,352.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$886.77
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
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 |
$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 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 |
$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 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 |
$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 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/ Contrast
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
1168196
|
|
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 |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
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 |
$312.67 |
| 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 |
$661.01
|
| Rate for Payer: Amerigroup Medicare |
$520.86
|
| 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 |
$515.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$654.60
|
| Rate for Payer: Medical Associates Commercial |
$859.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$515.70
|
| Rate for Payer: Midlands Choice Commercial |
$802.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$664.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$593.06
|
| Rate for Payer: United Healthcare Commercial |
$1,031.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$676.14
|
| Rate for Payer: Wellmark IA HMO WHPI |
$312.67
|
| Rate for Payer: Wellmark IA PPO |
$344.42
|
|
|
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
|
|
