|
XR Knee Standing AP Bilateral
|
Facility
IP
|
$139.00
|
|
|
Service Code
|
CPT 73565 50
|
| Hospital Charge Code |
1170291
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
|
|
XR Mandible Complete Minimum 4 Views
|
Facility
OP
|
$180.00
|
|
|
Service Code
|
CPT 70110
|
| Hospital Charge Code |
1170301
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| 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 |
$90.85
|
| Rate for Payer: Amerigroup Medicare |
$90.90
|
| Rate for Payer: Cash Price |
$144.00
|
| 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 |
$90.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.96
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$135.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Mandible Complete Minimum 4 Views
|
Facility
IP
|
$180.00
|
|
|
Service Code
|
CPT 70110
|
| Hospital Charge Code |
1170301
|
|
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 Mastoids Complete Bilateral
|
Facility
IP
|
$176.00
|
|
|
Service Code
|
CPT 70130 50
|
| Hospital Charge Code |
1170313
|
|
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 Mastoids Complete Bilateral
|
Facility
OP
|
$176.00
|
|
|
Service Code
|
CPT 70130 50
|
| Hospital Charge Code |
1170313
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$87.96 |
| 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 |
$88.83
|
| Rate for Payer: Amerigroup Medicare |
$88.88
|
| 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 |
$88.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$87.96
|
| Rate for Payer: Medical Associates Commercial |
$132.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$88.00
|
| Rate for Payer: Midlands Choice Commercial |
$123.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$89.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$132.00
|
| Rate for Payer: United Healthcare Commercial |
$158.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.84
|
|
|
XR Myelography Cervical Spine
|
Facility
OP
|
$1,211.00
|
|
|
Service Code
|
CPT 72240
|
| Hospital Charge Code |
1170319
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$605.26 |
| Max. Negotiated Rate |
$1,385.82 |
| Rate for Payer: Molina Healthcare Managed Medicaid |
$614.58
|
| Rate for Payer: Aetna of IA Commercial |
$1,089.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,089.90
|
| Rate for Payer: Aetna of IA Medicare |
$690.27
|
| Rate for Payer: Amerigroup Medicaid |
$611.19
|
| Rate for Payer: Amerigroup Medicare |
$611.56
|
| Rate for Payer: Cash Price |
$968.80
|
| Rate for Payer: Cash Price |
$968.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$908.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$605.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$605.26
|
| Rate for Payer: Medical Associates Commercial |
$908.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$605.50
|
| Rate for Payer: Midlands Choice Commercial |
$847.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$908.25
|
| Rate for Payer: United Healthcare Commercial |
$1,089.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$714.49
|
| Rate for Payer: Wellmark IA HMO |
$1,259.84
|
| Rate for Payer: Wellmark IA PPO |
$1,385.82
|
|
|
XR Myelography Cervical Spine
|
Facility
IP
|
$1,211.00
|
|
|
Service Code
|
CPT 72240
|
| Hospital Charge Code |
1170319
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$847.70 |
| Max. Negotiated Rate |
$1,089.90 |
| Rate for Payer: Aetna of IA Commercial |
$1,089.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,089.90
|
| Rate for Payer: Cash Price |
$968.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$908.25
|
| Rate for Payer: Medical Associates Commercial |
$908.25
|
| Rate for Payer: Midlands Choice Commercial |
$847.70
|
| Rate for Payer: United Healthcare Commercial |
$1,089.90
|
|
|
XR Myelography Lumbosacral
|
Facility
OP
|
$1,187.00
|
|
|
Service Code
|
CPT 72265
|
| Hospital Charge Code |
1170321
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$593.26 |
| Max. Negotiated Rate |
$1,385.82 |
| 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 |
$599.08
|
| Rate for Payer: Amerigroup Medicare |
$599.44
|
| Rate for Payer: Cash Price |
$949.60
|
| 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 |
$593.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$593.26
|
| Rate for Payer: Medical Associates Commercial |
$890.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$593.50
|
| Rate for Payer: Midlands Choice Commercial |
$830.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$602.40
|
| Rate for Payer: Partners Health Alliance Commercial |
$890.25
|
| Rate for Payer: United Healthcare Commercial |
$1,068.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$700.33
|
| Rate for Payer: Wellmark IA HMO |
$1,259.84
|
| Rate for Payer: Wellmark IA PPO |
$1,385.82
|
|
|
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 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 |
$59.52 |
| 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 |
$90.85
|
| Rate for Payer: Amerigroup Medicare |
$90.90
|
| Rate for Payer: Cash Price |
$144.00
|
| 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 |
$90.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.96
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$135.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Neck Soft Tissue
|
Facility
OP
|
$180.00
|
|
|
Service Code
|
CPT 70360
|
| Hospital Charge Code |
1170331
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| 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 |
$90.85
|
| Rate for Payer: Amerigroup Medicare |
$90.90
|
| Rate for Payer: Cash Price |
$144.00
|
| 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 |
$90.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.96
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$135.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
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 Optic Foramina Left
|
Facility
OP
|
$151.00
|
|
|
Service Code
|
CPT 70190 LT
|
| Hospital Charge Code |
1170333
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.47 |
| 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 |
$76.21
|
| Rate for Payer: Amerigroup Medicare |
$76.26
|
| 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 |
$75.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$75.47
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$113.25
|
| 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 |
$75.47 |
| 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 |
$76.21
|
| Rate for Payer: Amerigroup Medicare |
$76.26
|
| 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 |
$75.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$75.47
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$113.25
|
| 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 |
$113.45 |
| 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 |
$114.57
|
| Rate for Payer: Amerigroup Medicare |
$114.64
|
| 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 |
$113.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$113.45
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$113.50
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$115.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$170.25
|
| 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
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 Left
|
Facility
OP
|
$227.00
|
|
|
Service Code
|
CPT 70200 LT
|
| Hospital Charge Code |
1170339
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$113.45 |
| 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 |
$114.57
|
| Rate for Payer: Amerigroup Medicare |
$114.64
|
| 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 |
$113.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$113.45
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$113.50
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$115.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$170.25
|
| 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 Orbits Complete Right
|
Facility
OP
|
$227.00
|
|
|
Service Code
|
CPT 70200 RT
|
| Hospital Charge Code |
1170341
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$113.45 |
| 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 |
$114.57
|
| Rate for Payer: Amerigroup Medicare |
$114.64
|
| 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 |
$113.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$113.45
|
| Rate for Payer: Medical Associates Commercial |
$170.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$113.50
|
| Rate for Payer: Midlands Choice Commercial |
$158.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$115.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$170.25
|
| Rate for Payer: United Healthcare Commercial |
$204.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$133.93
|
|
|
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 |
$59.52 |
| 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 |
$75.70
|
| Rate for Payer: Amerigroup Medicare |
$75.75
|
| Rate for Payer: Cash Price |
$120.00
|
| 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 |
$75.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.97
|
| Rate for Payer: Medical Associates Commercial |
$112.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.00
|
| Rate for Payer: Midlands Choice Commercial |
$105.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.50
|
| Rate for Payer: United Healthcare Commercial |
$135.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$88.50
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
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
|
|
