|
XR Myelography Lumbosacral
|
Facility
|
IP
|
$1,187.00
|
|
|
Service Code
|
CPT 72265
|
| Hospital Charge Code |
1170321
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$830.90 |
| Max. Negotiated Rate |
$1,068.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,068.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,068.30
|
| Rate for Payer: Cash Price |
$949.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$890.25
|
| Rate for Payer: Medical Associates Commercial |
$890.25
|
| Rate for Payer: Midlands Choice Commercial |
$830.90
|
| Rate for Payer: United Healthcare Commercial |
$1,068.30
|
|
|
XR Myelography Lumbosacral
|
Facility
|
OP
|
$1,187.00
|
|
|
Service Code
|
CPT 72265
|
| Hospital Charge Code |
1170321
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$534.15 |
| Max. Negotiated Rate |
$1,068.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,068.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,068.30
|
| Rate for Payer: Aetna of IA Medicare |
$676.59
|
| Rate for Payer: Amerigroup Medicaid |
$684.66
|
| Rate for Payer: Amerigroup Medicare |
$539.49
|
| Rate for Payer: Cash Price |
$949.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$890.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$534.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$678.01
|
| Rate for Payer: Medical Associates Commercial |
$890.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$534.15
|
| Rate for Payer: Midlands Choice Commercial |
$830.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$687.99
|
| Rate for Payer: Partners Health Alliance Commercial |
$614.27
|
| Rate for Payer: United Healthcare Commercial |
$1,068.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$700.33
|
|
|
XR Nasal Bones Minimum 3 Views
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
1170329
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
XR Nasal Bones Minimum 3 Views
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
1170329
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
|
|
XR Neck Soft Tissue
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 70360
|
| Hospital Charge Code |
1170331
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
XR Neck Soft Tissue
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 70360
|
| Hospital Charge Code |
1170331
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
|
|
XR Optic Foramina Left
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 70190 LT
|
| Hospital Charge Code |
1170333
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$67.95 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Aetna of IA Medicare |
$86.07
|
| Rate for Payer: Amerigroup Medicaid |
$87.10
|
| Rate for Payer: Amerigroup Medicare |
$68.63
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$86.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.95
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$87.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$78.14
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$89.09
|
|
|
XR Optic Foramina Left
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 70190 LT
|
| Hospital Charge Code |
1170333
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
|
|
XR Optic Foramina Right
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 70190 RT
|
| Hospital Charge Code |
1170335
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
|
|
XR Optic Foramina Right
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 70190 RT
|
| Hospital Charge Code |
1170335
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$67.95 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Aetna of IA Medicare |
$86.07
|
| Rate for Payer: Amerigroup Medicaid |
$87.10
|
| Rate for Payer: Amerigroup Medicare |
$68.63
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$86.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.95
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$87.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$78.14
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$89.09
|
|
|
XR Orbits Complete Bilateral
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 70200 50
|
| Hospital Charge Code |
1170337
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.15 |
| Max. Negotiated Rate |
$204.30 |
| Rate for Payer: Aetna of IA Commercial |
$204.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$204.30
|
| Rate for Payer: Aetna of IA Medicare |
$129.39
|
| Rate for Payer: Amerigroup Medicaid |
$130.93
|
| Rate for Payer: Amerigroup Medicare |
$103.17
|
| Rate for Payer: Cash Price |
$181.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$170.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$102.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$129.66
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$102.15
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$131.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$117.47
|
| Rate for Payer: United Healthcare Commercial |
$204.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$133.93
|
|
|
XR Orbits Complete Bilateral
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 70200 50
|
| Hospital Charge Code |
1170337
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$158.90 |
| Max. Negotiated Rate |
$204.30 |
| Rate for Payer: Aetna of IA Commercial |
$204.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$204.30
|
| Rate for Payer: Cash Price |
$181.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$170.25
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: United Healthcare Commercial |
$204.30
|
|
|
XR Orbits Complete Left
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 70200 LT
|
| Hospital Charge Code |
1170339
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.15 |
| Max. Negotiated Rate |
$204.30 |
| Rate for Payer: Aetna of IA Commercial |
$204.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$204.30
|
| Rate for Payer: Aetna of IA Medicare |
$129.39
|
| Rate for Payer: Amerigroup Medicaid |
$130.93
|
| Rate for Payer: Amerigroup Medicare |
$103.17
|
| Rate for Payer: Cash Price |
$181.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$170.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$102.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$129.66
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$102.15
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$131.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$117.47
|
| Rate for Payer: United Healthcare Commercial |
$204.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$133.93
|
|
|
XR Orbits Complete Left
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 70200 LT
|
| Hospital Charge Code |
1170339
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$158.90 |
| Max. Negotiated Rate |
$204.30 |
| Rate for Payer: Aetna of IA Commercial |
$204.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$204.30
|
| Rate for Payer: Cash Price |
$181.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$170.25
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: United Healthcare Commercial |
$204.30
|
|
|
XR Orbits Complete Right
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
CPT 70200 RT
|
| Hospital Charge Code |
1170341
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.15 |
| Max. Negotiated Rate |
$204.30 |
| Rate for Payer: Aetna of IA Commercial |
$204.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$204.30
|
| Rate for Payer: Aetna of IA Medicare |
$129.39
|
| Rate for Payer: Amerigroup Medicaid |
$130.93
|
| Rate for Payer: Amerigroup Medicare |
$103.17
|
| Rate for Payer: Cash Price |
$181.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$170.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$102.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$129.66
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$102.15
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$131.57
|
| Rate for Payer: Partners Health Alliance Commercial |
$117.47
|
| Rate for Payer: United Healthcare Commercial |
$204.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$133.93
|
|
|
XR Orbits Complete Right
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 70200 RT
|
| Hospital Charge Code |
1170341
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$158.90 |
| Max. Negotiated Rate |
$204.30 |
| Rate for Payer: Aetna of IA Commercial |
$204.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$204.30
|
| Rate for Payer: Cash Price |
$181.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$170.25
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: United Healthcare Commercial |
$204.30
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1170351
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1170351
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of IA Commercial |
$135.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.00
|
| Rate for Payer: Aetna of IA Medicare |
$85.50
|
| Rate for Payer: Amerigroup Medicaid |
$86.52
|
| Rate for Payer: Amerigroup Medicare |
$68.17
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$85.68
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$86.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$77.62
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$88.50
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
1170353
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$114.10 |
| Max. Negotiated Rate |
$146.70 |
| Rate for Payer: Aetna of IA Commercial |
$146.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$146.70
|
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$122.25
|
| Rate for Payer: Medical Associates Commercial |
$122.25
|
| Rate for Payer: Midlands Choice Commercial |
$114.10
|
| Rate for Payer: United Healthcare Commercial |
$146.70
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
1170353
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.35 |
| Max. Negotiated Rate |
$146.70 |
| Rate for Payer: Aetna of IA Commercial |
$146.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$146.70
|
| Rate for Payer: Aetna of IA Medicare |
$92.91
|
| Rate for Payer: Amerigroup Medicaid |
$94.02
|
| Rate for Payer: Amerigroup Medicare |
$74.08
|
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$122.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$93.11
|
| Rate for Payer: Medical Associates Commercial |
$122.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.35
|
| Rate for Payer: Midlands Choice Commercial |
$114.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$94.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$84.35
|
| Rate for Payer: United Healthcare Commercial |
$146.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$96.17
|
|
|
XR Pelvis + Hips Infant/Child
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 73540
|
| Hospital Charge Code |
1170349
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna of IA Commercial |
$158.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$158.40
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.00
|
| Rate for Payer: Medical Associates Commercial |
$132.00
|
| Rate for Payer: Midlands Choice Commercial |
$123.20
|
| Rate for Payer: United Healthcare Commercial |
$158.40
|
|
|
XR Pelvis + Hips Infant/Child
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 73540
|
| Hospital Charge Code |
1170349
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$79.20 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna of IA Commercial |
$158.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$158.40
|
| Rate for Payer: Aetna of IA Medicare |
$100.32
|
| Rate for Payer: Amerigroup Medicaid |
$101.52
|
| Rate for Payer: Amerigroup Medicare |
$79.99
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$132.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$79.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.53
|
| Rate for Payer: Medical Associates Commercial |
$132.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.20
|
| Rate for Payer: Midlands Choice Commercial |
$123.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.08
|
| Rate for Payer: United Healthcare Commercial |
$158.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.84
|
|
|
XR Ribs 2 Views Bilateral
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
CPT 71110 50
|
| Hospital Charge Code |
4806783
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$141.40 |
| Max. Negotiated Rate |
$181.80 |
| Rate for Payer: Aetna of IA Commercial |
$181.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$181.80
|
| Rate for Payer: Cash Price |
$161.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$151.50
|
| Rate for Payer: Medical Associates Commercial |
$151.50
|
| Rate for Payer: Midlands Choice Commercial |
$141.40
|
| Rate for Payer: United Healthcare Commercial |
$181.80
|
|
|
XR Ribs 2 Views Bilateral
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
CPT 71110 50
|
| Hospital Charge Code |
4806783
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$90.90 |
| Max. Negotiated Rate |
$181.80 |
| Rate for Payer: Aetna of IA Commercial |
$181.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$181.80
|
| Rate for Payer: Aetna of IA Medicare |
$115.14
|
| Rate for Payer: Amerigroup Medicaid |
$116.51
|
| Rate for Payer: Amerigroup Medicare |
$91.81
|
| Rate for Payer: Cash Price |
$161.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$151.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$90.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$115.38
|
| Rate for Payer: Medical Associates Commercial |
$151.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.90
|
| Rate for Payer: Midlands Choice Commercial |
$141.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$117.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$104.53
|
| Rate for Payer: United Healthcare Commercial |
$181.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$119.18
|
|
|
XR Ribs 2 Views Left
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 71100 LT
|
| Hospital Charge Code |
1170371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$66.15 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna of IA Commercial |
$132.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$132.30
|
| Rate for Payer: Aetna of IA Medicare |
$83.79
|
| Rate for Payer: Amerigroup Medicaid |
$84.79
|
| Rate for Payer: Amerigroup Medicare |
$66.81
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$110.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$66.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$83.97
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$66.15
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$85.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$76.07
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.73
|
|
