|
MRI Pelvis w/ Contrast
|
Facility
|
IP
|
$1,640.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
1169026
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,148.00 |
| Max. Negotiated Rate |
$1,476.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,476.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,476.00
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,230.00
|
| Rate for Payer: Medical Associates Commercial |
$1,230.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,148.00
|
| Rate for Payer: United Healthcare Commercial |
$1,476.00
|
|
|
MRI Pelvis w/ Contrast
|
Facility
|
OP
|
$1,640.00
|
|
|
Service Code
|
CPT 72196
|
| Hospital Charge Code |
1169026
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$819.67 |
| Max. Negotiated Rate |
$1,476.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,476.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,476.00
|
| Rate for Payer: Aetna of IA Medicare |
$934.80
|
| Rate for Payer: Amerigroup Medicaid |
$827.71
|
| Rate for Payer: Amerigroup Medicare |
$828.20
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,230.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$820.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$819.67
|
| Rate for Payer: Medical Associates Commercial |
$1,230.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$820.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,148.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$832.30
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$831.81
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,230.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,230.00
|
| Rate for Payer: United Healthcare Commercial |
$1,476.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$967.60
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
|
MRI Pelvis w/o Contrast
|
Facility
|
IP
|
$1,530.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
1169028
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,071.00 |
| Max. Negotiated Rate |
$1,377.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,377.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,377.00
|
| Rate for Payer: Cash Price |
$1,224.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,147.50
|
| Rate for Payer: Medical Associates Commercial |
$1,147.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,071.00
|
| Rate for Payer: United Healthcare Commercial |
$1,377.00
|
|
|
MRI Pelvis w/o Contrast
|
Facility
|
OP
|
$1,530.00
|
|
|
Service Code
|
CPT 72195
|
| Hospital Charge Code |
1169028
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$764.69 |
| Max. Negotiated Rate |
$1,377.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,377.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,377.00
|
| Rate for Payer: Aetna of IA Medicare |
$872.10
|
| Rate for Payer: Amerigroup Medicaid |
$772.19
|
| Rate for Payer: Amerigroup Medicare |
$772.65
|
| Rate for Payer: Cash Price |
$1,224.00
|
| Rate for Payer: Cash Price |
$1,224.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,147.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$765.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$764.69
|
| Rate for Payer: Medical Associates Commercial |
$1,147.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$765.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,071.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$776.48
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$776.02
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,147.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,147.50
|
| Rate for Payer: United Healthcare Commercial |
$1,377.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$902.70
|
| Rate for Payer: Wellmark IA HMO |
$983.32
|
| Rate for Payer: Wellmark IA PPO |
$1,081.65
|
|
|
MRI Pelvis w/ + w/o Contrast
|
Facility
|
OP
|
$1,640.00
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
1169024
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$819.67 |
| Max. Negotiated Rate |
$1,476.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,476.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,476.00
|
| Rate for Payer: Aetna of IA Medicare |
$934.80
|
| Rate for Payer: Amerigroup Medicaid |
$827.71
|
| Rate for Payer: Amerigroup Medicare |
$828.20
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,230.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$820.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$819.67
|
| Rate for Payer: Medical Associates Commercial |
$1,230.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$820.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,148.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$832.30
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$831.81
|
| Rate for Payer: Oscar Health of IA Commercial |
$1,230.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,230.00
|
| Rate for Payer: United Healthcare Commercial |
$1,476.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$967.60
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
|
MRI Pelvis w/ + w/o Contrast
|
Facility
|
IP
|
$1,640.00
|
|
|
Service Code
|
CPT 72197
|
| Hospital Charge Code |
1169024
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,148.00 |
| Max. Negotiated Rate |
$1,476.00 |
| Rate for Payer: Aetna of IA Commercial |
$1,476.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,476.00
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,230.00
|
| Rate for Payer: Medical Associates Commercial |
$1,230.00
|
| Rate for Payer: Midlands Choice Commercial |
$1,148.00
|
| Rate for Payer: United Healthcare Commercial |
$1,476.00
|
|
|
MRI Shoulder w/ Contrast Left
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
1169038
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$717.50 |
| Max. Negotiated Rate |
$922.50 |
| Rate for Payer: Aetna of IA Commercial |
$922.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$922.50
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$768.75
|
| Rate for Payer: Medical Associates Commercial |
$768.75
|
| Rate for Payer: Midlands Choice Commercial |
$717.50
|
| Rate for Payer: United Healthcare Commercial |
$922.50
|
|
|
MRI Shoulder w/ Contrast Left
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
1169038
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$512.30 |
| Max. Negotiated Rate |
$1,357.18 |
| Rate for Payer: Aetna of IA Commercial |
$922.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$922.50
|
| Rate for Payer: Aetna of IA Medicare |
$584.25
|
| Rate for Payer: Amerigroup Medicaid |
$517.32
|
| Rate for Payer: Amerigroup Medicare |
$517.62
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$768.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$512.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$512.30
|
| Rate for Payer: Medical Associates Commercial |
$768.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$512.50
|
| Rate for Payer: Midlands Choice Commercial |
$717.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$520.19
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$519.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$768.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$768.75
|
| Rate for Payer: United Healthcare Commercial |
$922.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$604.75
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
1169040
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$717.50 |
| Max. Negotiated Rate |
$922.50 |
| Rate for Payer: Aetna of IA Commercial |
$922.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$922.50
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$768.75
|
| Rate for Payer: Medical Associates Commercial |
$768.75
|
| Rate for Payer: Midlands Choice Commercial |
$717.50
|
| Rate for Payer: United Healthcare Commercial |
$922.50
|
|
|
MRI Shoulder w/ Contrast Right
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
CPT 73222
|
| Hospital Charge Code |
1169040
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$512.30 |
| Max. Negotiated Rate |
$1,357.18 |
| Rate for Payer: Aetna of IA Commercial |
$922.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$922.50
|
| Rate for Payer: Aetna of IA Medicare |
$584.25
|
| Rate for Payer: Amerigroup Medicaid |
$517.32
|
| Rate for Payer: Amerigroup Medicare |
$517.62
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$768.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$512.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$512.30
|
| Rate for Payer: Medical Associates Commercial |
$768.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$512.50
|
| Rate for Payer: Midlands Choice Commercial |
$717.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$520.19
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$519.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$768.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$768.75
|
| Rate for Payer: United Healthcare Commercial |
$922.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$604.75
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
|
MRI Shoulder w/o Contrast Left
|
Facility
|
IP
|
$1,021.00
|
|
|
Service Code
|
CPT 73221
|
| Hospital Charge Code |
1169044
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$714.70 |
| Max. Negotiated Rate |
$918.90 |
| Rate for Payer: Aetna of IA Commercial |
$918.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$918.90
|
| Rate for Payer: Cash Price |
$816.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$765.75
|
| Rate for Payer: Medical Associates Commercial |
$765.75
|
| Rate for Payer: Midlands Choice Commercial |
$714.70
|
| Rate for Payer: United Healthcare Commercial |
$918.90
|
|
|
MRI Shoulder w/o Contrast Left
|
Facility
|
OP
|
$1,021.00
|
|
|
Service Code
|
CPT 73221
|
| Hospital Charge Code |
1169044
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$510.30 |
| Max. Negotiated Rate |
$1,081.65 |
| Rate for Payer: Aetna of IA Commercial |
$918.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$918.90
|
| Rate for Payer: Aetna of IA Medicare |
$581.97
|
| Rate for Payer: Amerigroup Medicaid |
$515.30
|
| Rate for Payer: Amerigroup Medicare |
$515.60
|
| Rate for Payer: Cash Price |
$816.80
|
| Rate for Payer: Cash Price |
$816.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$765.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$510.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$510.30
|
| Rate for Payer: Medical Associates Commercial |
$765.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$510.50
|
| Rate for Payer: Midlands Choice Commercial |
$714.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$518.16
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$517.85
|
| Rate for Payer: Oscar Health of IA Commercial |
$765.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$765.75
|
| Rate for Payer: United Healthcare Commercial |
$918.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$602.39
|
| Rate for Payer: Wellmark IA HMO |
$983.32
|
| Rate for Payer: Wellmark IA PPO |
$1,081.65
|
|
|
MRI Shoulder w/o Contrast Right
|
Facility
|
IP
|
$1,021.00
|
|
|
Service Code
|
CPT 73221
|
| Hospital Charge Code |
1169046
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$714.70 |
| Max. Negotiated Rate |
$918.90 |
| Rate for Payer: Aetna of IA Commercial |
$918.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$918.90
|
| Rate for Payer: Cash Price |
$816.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$765.75
|
| Rate for Payer: Medical Associates Commercial |
$765.75
|
| Rate for Payer: Midlands Choice Commercial |
$714.70
|
| Rate for Payer: United Healthcare Commercial |
$918.90
|
|
|
MRI Shoulder w/o Contrast Right
|
Facility
|
OP
|
$1,021.00
|
|
|
Service Code
|
CPT 73221
|
| Hospital Charge Code |
1169046
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$510.30 |
| Max. Negotiated Rate |
$1,081.65 |
| Rate for Payer: Aetna of IA Commercial |
$918.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$918.90
|
| Rate for Payer: Aetna of IA Medicare |
$581.97
|
| Rate for Payer: Amerigroup Medicaid |
$515.30
|
| Rate for Payer: Amerigroup Medicare |
$515.60
|
| Rate for Payer: Cash Price |
$816.80
|
| Rate for Payer: Cash Price |
$816.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$765.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$510.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$510.30
|
| Rate for Payer: Medical Associates Commercial |
$765.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$510.50
|
| Rate for Payer: Midlands Choice Commercial |
$714.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$518.16
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$517.85
|
| Rate for Payer: Oscar Health of IA Commercial |
$765.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$765.75
|
| Rate for Payer: United Healthcare Commercial |
$918.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$602.39
|
| Rate for Payer: Wellmark IA HMO |
$983.32
|
| Rate for Payer: Wellmark IA PPO |
$1,081.65
|
|
|
MRI Shoulder w/ + w/o Contrast Left
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
CPT 73223
|
| Hospital Charge Code |
1169032
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$512.30 |
| Max. Negotiated Rate |
$1,357.18 |
| Rate for Payer: Aetna of IA Commercial |
$922.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$922.50
|
| Rate for Payer: Aetna of IA Medicare |
$584.25
|
| Rate for Payer: Amerigroup Medicaid |
$517.32
|
| Rate for Payer: Amerigroup Medicare |
$517.62
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$768.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$512.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$512.30
|
| Rate for Payer: Medical Associates Commercial |
$768.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$512.50
|
| Rate for Payer: Midlands Choice Commercial |
$717.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$520.19
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$519.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$768.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$768.75
|
| Rate for Payer: United Healthcare Commercial |
$922.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$604.75
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
|
MRI Shoulder w/ + w/o Contrast Left
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
CPT 73223
|
| Hospital Charge Code |
1169032
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$717.50 |
| Max. Negotiated Rate |
$922.50 |
| Rate for Payer: Aetna of IA Commercial |
$922.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$922.50
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$768.75
|
| Rate for Payer: Medical Associates Commercial |
$768.75
|
| Rate for Payer: Midlands Choice Commercial |
$717.50
|
| Rate for Payer: United Healthcare Commercial |
$922.50
|
|
|
MRI Shoulder w/ + w/o Contrast Right
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
CPT 73223
|
| Hospital Charge Code |
1169034
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$717.50 |
| Max. Negotiated Rate |
$922.50 |
| Rate for Payer: Aetna of IA Commercial |
$922.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$922.50
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$768.75
|
| Rate for Payer: Medical Associates Commercial |
$768.75
|
| Rate for Payer: Midlands Choice Commercial |
$717.50
|
| Rate for Payer: United Healthcare Commercial |
$922.50
|
|
|
MRI Shoulder w/ + w/o Contrast Right
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
CPT 73223
|
| Hospital Charge Code |
1169034
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$512.30 |
| Max. Negotiated Rate |
$1,357.18 |
| Rate for Payer: Aetna of IA Commercial |
$922.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$922.50
|
| Rate for Payer: Aetna of IA Medicare |
$584.25
|
| Rate for Payer: Amerigroup Medicaid |
$517.32
|
| Rate for Payer: Amerigroup Medicare |
$517.62
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Cash Price |
$820.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$768.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$512.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$512.30
|
| Rate for Payer: Medical Associates Commercial |
$768.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$512.50
|
| Rate for Payer: Midlands Choice Commercial |
$717.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$520.19
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$519.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$768.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$768.75
|
| Rate for Payer: United Healthcare Commercial |
$922.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$604.75
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
|
MRI Spine Cervical w/ Contrast
|
Facility
|
IP
|
$956.00
|
|
|
Service Code
|
CPT 72142
|
| Hospital Charge Code |
1169052
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$669.20 |
| Max. Negotiated Rate |
$860.40 |
| Rate for Payer: Aetna of IA Commercial |
$860.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$860.40
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$717.00
|
| Rate for Payer: Medical Associates Commercial |
$717.00
|
| Rate for Payer: Midlands Choice Commercial |
$669.20
|
| Rate for Payer: United Healthcare Commercial |
$860.40
|
|
|
MRI Spine Cervical w/ Contrast
|
Facility
|
OP
|
$956.00
|
|
|
Service Code
|
CPT 72142
|
| Hospital Charge Code |
1169052
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$477.81 |
| Max. Negotiated Rate |
$1,357.18 |
| Rate for Payer: Aetna of IA Commercial |
$860.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$860.40
|
| Rate for Payer: Aetna of IA Medicare |
$544.92
|
| Rate for Payer: Amerigroup Medicaid |
$482.49
|
| Rate for Payer: Amerigroup Medicare |
$482.78
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$717.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$478.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$477.81
|
| Rate for Payer: Medical Associates Commercial |
$717.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$478.00
|
| Rate for Payer: Midlands Choice Commercial |
$669.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$485.17
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$484.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$717.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$717.00
|
| Rate for Payer: United Healthcare Commercial |
$860.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$564.04
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
|
MRI Spine Cervical w/o Contrast
|
Facility
|
IP
|
$894.00
|
|
|
Service Code
|
CPT 72141
|
| Hospital Charge Code |
1169054
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$625.80 |
| Max. Negotiated Rate |
$804.60 |
| Rate for Payer: Aetna of IA Commercial |
$804.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$804.60
|
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$670.50
|
| Rate for Payer: Medical Associates Commercial |
$670.50
|
| Rate for Payer: Midlands Choice Commercial |
$625.80
|
| Rate for Payer: United Healthcare Commercial |
$804.60
|
|
|
MRI Spine Cervical w/o Contrast
|
Facility
|
OP
|
$894.00
|
|
|
Service Code
|
CPT 72141
|
| Hospital Charge Code |
1169054
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$446.82 |
| Max. Negotiated Rate |
$1,081.65 |
| Rate for Payer: Aetna of IA Commercial |
$804.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$804.60
|
| Rate for Payer: Aetna of IA Medicare |
$509.58
|
| Rate for Payer: Amerigroup Medicaid |
$451.20
|
| Rate for Payer: Amerigroup Medicare |
$451.47
|
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Cash Price |
$715.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$670.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$447.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$446.82
|
| Rate for Payer: Medical Associates Commercial |
$670.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$447.00
|
| Rate for Payer: Midlands Choice Commercial |
$625.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$453.70
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$453.44
|
| Rate for Payer: Oscar Health of IA Commercial |
$670.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$670.50
|
| Rate for Payer: United Healthcare Commercial |
$804.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$527.46
|
| Rate for Payer: Wellmark IA HMO |
$983.32
|
| Rate for Payer: Wellmark IA PPO |
$1,081.65
|
|
|
MRI Spine Cervical w/ + w/o Contrast
|
Facility
|
OP
|
$956.00
|
|
|
Service Code
|
CPT 72156
|
| Hospital Charge Code |
1169050
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$477.81 |
| Max. Negotiated Rate |
$1,357.18 |
| Rate for Payer: Aetna of IA Commercial |
$860.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$860.40
|
| Rate for Payer: Aetna of IA Medicare |
$544.92
|
| Rate for Payer: Amerigroup Medicaid |
$482.49
|
| Rate for Payer: Amerigroup Medicare |
$482.78
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$717.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$478.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$477.81
|
| Rate for Payer: Medical Associates Commercial |
$717.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$478.00
|
| Rate for Payer: Midlands Choice Commercial |
$669.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$485.17
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$484.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$717.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$717.00
|
| Rate for Payer: United Healthcare Commercial |
$860.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$564.04
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
|
MRI Spine Cervical w/ + w/o Contrast
|
Facility
|
IP
|
$956.00
|
|
|
Service Code
|
CPT 72156
|
| Hospital Charge Code |
1169050
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$669.20 |
| Max. Negotiated Rate |
$860.40 |
| Rate for Payer: Aetna of IA Commercial |
$860.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$860.40
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$717.00
|
| Rate for Payer: Medical Associates Commercial |
$717.00
|
| Rate for Payer: Midlands Choice Commercial |
$669.20
|
| Rate for Payer: United Healthcare Commercial |
$860.40
|
|
|
MRI Spine Lumbar w/ Contrast
|
Facility
|
OP
|
$956.00
|
|
|
Service Code
|
CPT 72149
|
| Hospital Charge Code |
1169058
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$477.81 |
| Max. Negotiated Rate |
$1,357.18 |
| Rate for Payer: Aetna of IA Commercial |
$860.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$860.40
|
| Rate for Payer: Aetna of IA Medicare |
$544.92
|
| Rate for Payer: Amerigroup Medicaid |
$482.49
|
| Rate for Payer: Amerigroup Medicare |
$482.78
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Cash Price |
$764.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$717.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$478.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$477.81
|
| Rate for Payer: Medical Associates Commercial |
$717.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$478.00
|
| Rate for Payer: Midlands Choice Commercial |
$669.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$485.17
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$484.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$717.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$717.00
|
| Rate for Payer: United Healthcare Commercial |
$860.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$564.04
|
| Rate for Payer: Wellmark IA HMO |
$1,233.80
|
| Rate for Payer: Wellmark IA PPO |
$1,357.18
|
|
