|
XR Shoulder Complete Right
|
Facility
IP
|
$148.00
|
|
|
Service Code
|
CPT 73030 RT
|
| Hospital Charge Code |
1170417
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
|
|
XR Sinuses Paranasal < 3 Views
|
Facility
OP
|
$151.00
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
1170432
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Sinuses Paranasal < 3 Views
|
Facility
IP
|
$151.00
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
1170432
|
|
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 Sinuses Paranasal Complete
|
Facility
IP
|
$180.00
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
1170434
|
|
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 Sinuses Paranasal Complete
|
Facility
OP
|
$180.00
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
1170434
|
|
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 Skull < 4 Views
|
Facility
IP
|
$180.00
|
|
|
Service Code
|
CPT 70250
|
| Hospital Charge Code |
1170436
|
|
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 Skull < 4 Views
|
Facility
OP
|
$180.00
|
|
|
Service Code
|
CPT 70250
|
| Hospital Charge Code |
1170436
|
|
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 Skull Complete
|
Facility
OP
|
$268.00
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
1170438
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$241.20 |
| Rate for Payer: Aetna of IA Commercial |
$241.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$241.20
|
| Rate for Payer: Aetna of IA Medicare |
$152.76
|
| Rate for Payer: Amerigroup Medicaid |
$135.26
|
| Rate for Payer: Amerigroup Medicare |
$135.34
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$201.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$134.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$133.95
|
| Rate for Payer: Medical Associates Commercial |
$201.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$134.00
|
| Rate for Payer: Midlands Choice Commercial |
$187.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$136.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$201.00
|
| Rate for Payer: United Healthcare Commercial |
$241.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$158.12
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Skull Complete
|
Facility
IP
|
$268.00
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
1170438
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$187.60 |
| Max. Negotiated Rate |
$241.20 |
| Rate for Payer: Aetna of IA Commercial |
$241.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$241.20
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$201.00
|
| Rate for Payer: Medical Associates Commercial |
$201.00
|
| Rate for Payer: Midlands Choice Commercial |
$187.60
|
| Rate for Payer: United Healthcare Commercial |
$241.20
|
|
|
XR Small Bowel w/ Serial Films
|
Facility
OP
|
$437.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
1170442
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$178.56 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of IA Commercial |
$393.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$393.30
|
| Rate for Payer: Aetna of IA Medicare |
$249.09
|
| Rate for Payer: Amerigroup Medicaid |
$220.55
|
| Rate for Payer: Amerigroup Medicare |
$220.68
|
| Rate for Payer: Cash Price |
$349.60
|
| Rate for Payer: Cash Price |
$349.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$327.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$218.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$218.41
|
| Rate for Payer: Medical Associates Commercial |
$327.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$218.50
|
| Rate for Payer: Midlands Choice Commercial |
$305.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$221.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$327.75
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$257.83
|
| Rate for Payer: Wellmark IA HMO |
$178.56
|
| Rate for Payer: Wellmark IA PPO |
$196.42
|
|
|
XR Small Bowel w/ Serial Films
|
Facility
IP
|
$437.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
1170442
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$305.90 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of IA Commercial |
$393.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$393.30
|
| Rate for Payer: Cash Price |
$349.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$327.75
|
| Rate for Payer: Medical Associates Commercial |
$327.75
|
| Rate for Payer: Midlands Choice Commercial |
$305.90
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
|
|
XR Speech Evaluation Dyname Pharyngeal
|
Facility
IP
|
$389.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
1170444
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$272.30 |
| Max. Negotiated Rate |
$350.10 |
| Rate for Payer: Aetna of IA Commercial |
$350.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$350.10
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$291.75
|
| Rate for Payer: Medical Associates Commercial |
$291.75
|
| Rate for Payer: Midlands Choice Commercial |
$272.30
|
| Rate for Payer: United Healthcare Commercial |
$350.10
|
|
|
XR Speech Evaluation Dyname Pharyngeal
|
Facility
OP
|
$389.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
1170444
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$178.56 |
| Max. Negotiated Rate |
$350.10 |
| Rate for Payer: Aetna of IA Commercial |
$350.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$350.10
|
| Rate for Payer: Aetna of IA Medicare |
$221.73
|
| Rate for Payer: Amerigroup Medicaid |
$196.33
|
| Rate for Payer: Amerigroup Medicare |
$196.44
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$291.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$194.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$194.42
|
| Rate for Payer: Medical Associates Commercial |
$291.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$194.50
|
| Rate for Payer: Midlands Choice Commercial |
$272.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$197.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$291.75
|
| Rate for Payer: United Healthcare Commercial |
$350.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$229.51
|
| Rate for Payer: Wellmark IA HMO |
$178.56
|
| Rate for Payer: Wellmark IA PPO |
$196.42
|
|
|
XR Spine 1 View Cervical
|
Facility
OP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170446
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$180.90 |
| Rate for Payer: Aetna of IA Commercial |
$180.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$180.90
|
| Rate for Payer: Aetna of IA Medicare |
$114.57
|
| Rate for Payer: Amerigroup Medicaid |
$101.44
|
| Rate for Payer: Amerigroup Medicare |
$101.50
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$150.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$100.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.46
|
| Rate for Payer: Medical Associates Commercial |
$150.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$100.50
|
| Rate for Payer: Midlands Choice Commercial |
$140.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$150.75
|
| Rate for Payer: United Healthcare Commercial |
$180.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$118.59
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine 1 View Cervical
|
Facility
IP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170446
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$140.70 |
| Max. Negotiated Rate |
$180.90 |
| Rate for Payer: Aetna of IA Commercial |
$180.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$180.90
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$150.75
|
| Rate for Payer: Medical Associates Commercial |
$150.75
|
| Rate for Payer: Midlands Choice Commercial |
$140.70
|
| Rate for Payer: United Healthcare Commercial |
$180.90
|
|
|
XR Spine 1 View Lumbar
|
Facility
IP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170448
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$140.70 |
| Max. Negotiated Rate |
$180.90 |
| Rate for Payer: Aetna of IA Commercial |
$180.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$180.90
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$150.75
|
| Rate for Payer: Medical Associates Commercial |
$150.75
|
| Rate for Payer: Midlands Choice Commercial |
$140.70
|
| Rate for Payer: United Healthcare Commercial |
$180.90
|
|
|
XR Spine 1 View Lumbar
|
Facility
OP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170448
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$180.90 |
| Rate for Payer: United Healthcare Commercial |
$180.90
|
| Rate for Payer: Aetna of IA Commercial |
$180.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$180.90
|
| Rate for Payer: Aetna of IA Medicare |
$114.57
|
| Rate for Payer: Amerigroup Medicaid |
$101.44
|
| Rate for Payer: Amerigroup Medicare |
$101.50
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$150.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$100.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.46
|
| Rate for Payer: Medical Associates Commercial |
$150.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$100.50
|
| Rate for Payer: Midlands Choice Commercial |
$140.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$150.75
|
| Rate for Payer: United Healthcare Managed Medicare |
$118.59
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine 1 View Thoracic
|
Facility
OP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170450
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$180.90 |
| Rate for Payer: Aetna of IA Commercial |
$180.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$180.90
|
| Rate for Payer: Aetna of IA Medicare |
$114.57
|
| Rate for Payer: Amerigroup Medicaid |
$101.44
|
| Rate for Payer: Amerigroup Medicare |
$101.50
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$150.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$100.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.46
|
| Rate for Payer: Medical Associates Commercial |
$150.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$100.50
|
| Rate for Payer: Midlands Choice Commercial |
$140.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$150.75
|
| Rate for Payer: United Healthcare Commercial |
$180.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$118.59
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine 1 View Thoracic
|
Facility
IP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170450
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$140.70 |
| Max. Negotiated Rate |
$180.90 |
| Rate for Payer: Aetna of IA Commercial |
$180.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$180.90
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$150.75
|
| Rate for Payer: Medical Associates Commercial |
$150.75
|
| Rate for Payer: Midlands Choice Commercial |
$140.70
|
| Rate for Payer: United Healthcare Commercial |
$180.90
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
OP
|
$155.00
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
1170452
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$139.50 |
| Rate for Payer: Aetna of IA Commercial |
$139.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$139.50
|
| Rate for Payer: Aetna of IA Medicare |
$88.35
|
| Rate for Payer: Amerigroup Medicaid |
$78.23
|
| Rate for Payer: Amerigroup Medicare |
$78.28
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$116.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$77.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$77.47
|
| Rate for Payer: Medical Associates Commercial |
$116.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$77.50
|
| Rate for Payer: Midlands Choice Commercial |
$108.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$78.66
|
| Rate for Payer: Partners Health Alliance Commercial |
$116.25
|
| Rate for Payer: United Healthcare Commercial |
$139.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$91.45
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine Cervical 2 or 3 Views
|
Facility
IP
|
$155.00
|
|
|
Service Code
|
CPT 72040
|
| Hospital Charge Code |
1170452
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$139.50 |
| Rate for Payer: Aetna of IA Commercial |
$139.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$139.50
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$116.25
|
| Rate for Payer: Medical Associates Commercial |
$116.25
|
| Rate for Payer: Midlands Choice Commercial |
$108.50
|
| Rate for Payer: United Healthcare Commercial |
$139.50
|
|
|
XR Spine Cervical Comp w/ Obliques
|
Facility
OP
|
$217.00
|
|
|
Service Code
|
CPT 72050
|
| Hospital Charge Code |
1170454
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna of IA Commercial |
$195.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$195.30
|
| Rate for Payer: Aetna of IA Medicare |
$123.69
|
| Rate for Payer: Amerigroup Medicaid |
$109.52
|
| Rate for Payer: Amerigroup Medicare |
$109.58
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$162.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$108.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$108.46
|
| Rate for Payer: Medical Associates Commercial |
$162.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$108.50
|
| Rate for Payer: Midlands Choice Commercial |
$151.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$110.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$162.75
|
| Rate for Payer: United Healthcare Commercial |
$195.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$128.03
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine Cervical Comp w/ Obliques
|
Facility
IP
|
$217.00
|
|
|
Service Code
|
CPT 72050
|
| Hospital Charge Code |
1170454
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.90 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna of IA Commercial |
$195.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$195.30
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$162.75
|
| Rate for Payer: Medical Associates Commercial |
$162.75
|
| Rate for Payer: Midlands Choice Commercial |
$151.90
|
| Rate for Payer: United Healthcare Commercial |
$195.30
|
|
|
XR Spine Cervical Minimum 4 Views
|
Facility
IP
|
$217.00
|
|
|
Service Code
|
CPT 72050
|
| Hospital Charge Code |
1170461
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.90 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna of IA Commercial |
$195.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$195.30
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$162.75
|
| Rate for Payer: Medical Associates Commercial |
$162.75
|
| Rate for Payer: Midlands Choice Commercial |
$151.90
|
| Rate for Payer: United Healthcare Commercial |
$195.30
|
|
|
XR Spine Cervical Minimum 4 Views
|
Facility
OP
|
$217.00
|
|
|
Service Code
|
CPT 72050
|
| Hospital Charge Code |
1170461
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna of IA Commercial |
$195.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$195.30
|
| Rate for Payer: Aetna of IA Medicare |
$123.69
|
| Rate for Payer: Amerigroup Medicaid |
$109.52
|
| Rate for Payer: Amerigroup Medicare |
$109.58
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$162.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$108.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$108.46
|
| Rate for Payer: Medical Associates Commercial |
$162.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$108.50
|
| Rate for Payer: Midlands Choice Commercial |
$151.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$110.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$162.75
|
| Rate for Payer: United Healthcare Commercial |
$195.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$128.03
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
