|
CT Pelvis w/ + w/o Contrast
|
Facility
|
OP
|
$1,672.00
|
|
|
Service Code
|
CPT 72194
|
| Hospital Charge Code |
1168194
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$752.40 |
| Max. Negotiated Rate |
$1,504.80 |
| Rate for Payer: Aetna of IA Commercial |
$1,504.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,504.80
|
| Rate for Payer: Aetna of IA Medicare |
$953.04
|
| Rate for Payer: Amerigroup Medicaid |
$964.41
|
| Rate for Payer: Amerigroup Medicare |
$759.92
|
| Rate for Payer: Cash Price |
$1,337.60
|
| Rate for Payer: Cash Price |
$1,337.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,254.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$752.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$955.05
|
| Rate for Payer: Medical Associates Commercial |
$1,254.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$752.40
|
| Rate for Payer: Midlands Choice Commercial |
$1,170.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$969.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$865.26
|
| Rate for Payer: United Healthcare Commercial |
$1,504.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$986.48
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT Pelvis w/ + w/o Contrast
|
Facility
|
IP
|
$1,672.00
|
|
|
Service Code
|
CPT 72194
|
| Hospital Charge Code |
1168194
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,170.40 |
| Max. Negotiated Rate |
$1,504.80 |
| Rate for Payer: Aetna of IA Commercial |
$1,504.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,504.80
|
| Rate for Payer: Cash Price |
$1,337.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,254.00
|
| Rate for Payer: Medical Associates Commercial |
$1,254.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,170.40
|
| Rate for Payer: United Healthcare Commercial |
$1,504.80
|
|
|
C. trach N. gonorrhea DNA DMCL
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
CPT 87491
|
| Hospital Charge Code |
8037504
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$63.90 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna of IA Commercial |
$127.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.80
|
| Rate for Payer: Aetna of IA Medicare |
$80.94
|
| Rate for Payer: Amerigroup Medicaid |
$81.91
|
| Rate for Payer: Amerigroup Medicare |
$64.54
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$63.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.11
|
| Rate for Payer: Medical Associates Commercial |
$106.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$63.90
|
| Rate for Payer: Midlands Choice Commercial |
$99.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.30
|
| Rate for Payer: Partners Health Alliance Commercial |
$73.48
|
| Rate for Payer: United Healthcare Commercial |
$127.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$83.78
|
| Rate for Payer: Wellmark IA HMO WHPI |
$86.50
|
| Rate for Payer: Wellmark IA PPO |
$95.28
|
|
|
C. trach N. gonorrhea DNA DMCL
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
CPT 87491
|
| Hospital Charge Code |
8037504
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna of IA Commercial |
$127.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$127.80
|
| Rate for Payer: Cash Price |
$113.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$106.50
|
| Rate for Payer: Medical Associates Commercial |
$106.50
|
| Rate for Payer: Midlands Choice Commercial |
$99.40
|
| Rate for Payer: United Healthcare Commercial |
$127.80
|
|
|
CT Shoulder w/ Contrast Left
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201 LT
|
| Hospital Charge Code |
1168214
|
|
Hospital Revenue Code
|
350
|
| 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 Shoulder w/ Contrast Left
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201 LT
|
| Hospital Charge Code |
1168214
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,005.20 |
| Max. Negotiated Rate |
$1,292.40 |
| Rate for Payer: Aetna of IA Commercial |
$1,292.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,292.40
|
| Rate for Payer: Cash Price |
$1,148.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,077.00
|
| Rate for Payer: Medical Associates Commercial |
$1,077.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,005.20
|
| Rate for Payer: United Healthcare Commercial |
$1,292.40
|
|
|
CT Shoulder w/ Contrast Right
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201 RT
|
| Hospital Charge Code |
1168216
|
|
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 Shoulder w/ Contrast Right
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
CPT 73201 RT
|
| Hospital Charge Code |
1168216
|
|
Hospital Revenue Code
|
350
|
| 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 Shoulder w/o Contrast Left
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73200 LT
|
| Hospital Charge Code |
1168220
|
|
Hospital Revenue Code
|
350
|
| 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 Shoulder w/o Contrast Left
|
Facility
|
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73200 LT
|
| Hospital Charge Code |
1168220
|
|
Hospital Revenue Code
|
350
|
| 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 Shoulder w/o Contrast Right
|
Facility
|
OP
|
$1,121.00
|
|
|
Service Code
|
CPT 73200 RT
|
| Hospital Charge Code |
1168222
|
|
Hospital Revenue Code
|
350
|
| 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 Shoulder w/o Contrast Right
|
Facility
|
IP
|
$1,121.00
|
|
|
Service Code
|
CPT 73200 RT
|
| Hospital Charge Code |
1168222
|
|
Hospital Revenue Code
|
350
|
| 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 Shoulder w/ + w/o Contrast Left
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
CPT 73202 LT
|
| Hospital Charge Code |
1168208
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$594.45 |
| Max. Negotiated Rate |
$1,188.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,188.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,188.90
|
| Rate for Payer: Aetna of IA Medicare |
$752.97
|
| Rate for Payer: Amerigroup Medicaid |
$761.95
|
| Rate for Payer: Amerigroup Medicare |
$600.39
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$990.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$594.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$754.56
|
| Rate for Payer: Medical Associates Commercial |
$990.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$594.45
|
| Rate for Payer: Midlands Choice Commercial |
$924.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$765.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$683.62
|
| Rate for Payer: United Healthcare Commercial |
$1,188.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$779.39
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT Shoulder w/ + w/o Contrast Left
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
CPT 73202 LT
|
| Hospital Charge Code |
1168208
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$924.70 |
| Max. Negotiated Rate |
$1,188.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,188.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,188.90
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$990.75
|
| Rate for Payer: Medical Associates Commercial |
$990.75
|
| Rate for Payer: Midlands Choice Commercial |
$924.70
|
| Rate for Payer: United Healthcare Commercial |
$1,188.90
|
|
|
CT Shoulder w/ + w/o Contrast Right
|
Facility
|
OP
|
$1,321.00
|
|
|
Service Code
|
CPT 73202 RT
|
| Hospital Charge Code |
1168210
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$594.45 |
| Max. Negotiated Rate |
$1,188.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,188.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,188.90
|
| Rate for Payer: Aetna of IA Medicare |
$752.97
|
| Rate for Payer: Amerigroup Medicaid |
$761.95
|
| Rate for Payer: Amerigroup Medicare |
$600.39
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$990.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$594.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$754.56
|
| Rate for Payer: Medical Associates Commercial |
$990.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$594.45
|
| Rate for Payer: Midlands Choice Commercial |
$924.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$765.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$683.62
|
| Rate for Payer: United Healthcare Commercial |
$1,188.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$779.39
|
| Rate for Payer: Wellmark IA HMO WHPI |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT Shoulder w/ + w/o Contrast Right
|
Facility
|
IP
|
$1,321.00
|
|
|
Service Code
|
CPT 73202 RT
|
| Hospital Charge Code |
1168210
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$924.70 |
| Max. Negotiated Rate |
$1,188.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,188.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,188.90
|
| Rate for Payer: Cash Price |
$1,056.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$990.75
|
| Rate for Payer: Medical Associates Commercial |
$990.75
|
| Rate for Payer: Midlands Choice Commercial |
$924.70
|
| Rate for Payer: United Healthcare Commercial |
$1,188.90
|
|
|
CT Sinus w/ Contrast
|
Facility
|
OP
|
$1,540.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
1168226
|
|
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 Sinus w/ Contrast
|
Facility
|
IP
|
$1,540.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
1168226
|
|
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 Sinus w/o Contrast
|
Facility
|
OP
|
$1,180.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
1168228
|
|
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 Sinus w/o Contrast
|
Facility
|
IP
|
$1,180.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
1168228
|
|
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 Sinus w/ + w/o Contrast
|
Facility
|
OP
|
$1,503.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
1168224
|
|
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 Sinus w/ + w/o Contrast
|
Facility
|
IP
|
$1,503.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
1168224
|
|
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 Soft Tissue Neck w/ Contrast
|
Facility
|
OP
|
$1,445.00
|
|
|
Service Code
|
CPT 70491
|
| Hospital Charge Code |
1168232
|
|
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 |
$832.37
|
| Rate for Payer: Wellmark IA PPO |
$916.89
|
|
|
CT Soft Tissue Neck w/ Contrast
|
Facility
|
IP
|
$1,445.00
|
|
|
Service Code
|
CPT 70491
|
| Hospital Charge Code |
1168232
|
|
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 Soft Tissue Neck w/o Contrast
|
Facility
|
OP
|
$1,180.00
|
|
|
Service Code
|
CPT 70490
|
| Hospital Charge Code |
1168234
|
|
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
|
|
