|
XR Spine Cervical w/ Flext and/or Ext
|
Facility
OP
|
$297.00
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
1170463
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$267.30 |
| Rate for Payer: Aetna of IA Commercial |
$267.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$267.30
|
| Rate for Payer: Aetna of IA Medicare |
$169.29
|
| Rate for Payer: Amerigroup Medicaid |
$149.90
|
| Rate for Payer: Amerigroup Medicare |
$149.98
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$222.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$148.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$148.44
|
| Rate for Payer: Medical Associates Commercial |
$222.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$148.50
|
| Rate for Payer: Midlands Choice Commercial |
$207.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$150.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$222.75
|
| Rate for Payer: United Healthcare Commercial |
$267.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$175.23
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine Cervical w/ Flext and/or Ext
|
Facility
IP
|
$297.00
|
|
|
Service Code
|
CPT 72052
|
| Hospital Charge Code |
1170463
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$207.90 |
| Max. Negotiated Rate |
$267.30 |
| Rate for Payer: Aetna of IA Commercial |
$267.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$267.30
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$222.75
|
| Rate for Payer: Medical Associates Commercial |
$222.75
|
| Rate for Payer: Midlands Choice Commercial |
$207.90
|
| Rate for Payer: United Healthcare Commercial |
$267.30
|
|
|
XR Spine Lumbar Flexion + Extension
|
Facility
OP
|
$287.00
|
|
|
Service Code
|
CPT 72114
|
| Hospital Charge Code |
1170467
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$258.30 |
| Rate for Payer: Aetna of IA Commercial |
$258.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$258.30
|
| Rate for Payer: Aetna of IA Medicare |
$163.59
|
| Rate for Payer: Amerigroup Medicaid |
$144.85
|
| Rate for Payer: Amerigroup Medicare |
$144.94
|
| Rate for Payer: Cash Price |
$229.60
|
| Rate for Payer: Cash Price |
$229.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$215.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$143.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$143.44
|
| Rate for Payer: Medical Associates Commercial |
$215.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$143.50
|
| Rate for Payer: Midlands Choice Commercial |
$200.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$145.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$215.25
|
| Rate for Payer: United Healthcare Commercial |
$258.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$169.33
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine Lumbar Flexion + Extension
|
Facility
IP
|
$287.00
|
|
|
Service Code
|
CPT 72114
|
| Hospital Charge Code |
1170467
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$200.90 |
| Max. Negotiated Rate |
$258.30 |
| Rate for Payer: Aetna of IA Commercial |
$258.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$258.30
|
| Rate for Payer: Cash Price |
$229.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$215.25
|
| Rate for Payer: Medical Associates Commercial |
$215.25
|
| Rate for Payer: Midlands Choice Commercial |
$200.90
|
| Rate for Payer: United Healthcare Commercial |
$258.30
|
|
|
XR Spine Lumbosacral 2 or 3 Views
|
Facility
IP
|
$176.00
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
1170470
|
|
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 Spine Lumbosacral 2 or 3 Views
|
Facility
OP
|
$176.00
|
|
|
Service Code
|
CPT 72100
|
| Hospital Charge Code |
1170470
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine Lumbosacral Minimum 4 Views
|
Facility
OP
|
$237.00
|
|
|
Service Code
|
CPT 72110
|
| Hospital Charge Code |
1170476
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$213.30 |
| Rate for Payer: Aetna of IA Commercial |
$213.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$213.30
|
| Rate for Payer: Aetna of IA Medicare |
$135.09
|
| Rate for Payer: Amerigroup Medicaid |
$119.61
|
| Rate for Payer: Amerigroup Medicare |
$119.68
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$177.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$118.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$118.45
|
| Rate for Payer: Medical Associates Commercial |
$177.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$118.50
|
| Rate for Payer: Midlands Choice Commercial |
$165.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$120.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$177.75
|
| Rate for Payer: United Healthcare Commercial |
$213.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$139.83
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine Lumbosacral Minimum 4 Views
|
Facility
IP
|
$237.00
|
|
|
Service Code
|
CPT 72110
|
| Hospital Charge Code |
1170476
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$165.90 |
| Max. Negotiated Rate |
$213.30 |
| Rate for Payer: Aetna of IA Commercial |
$213.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$213.30
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$177.75
|
| Rate for Payer: Medical Associates Commercial |
$177.75
|
| Rate for Payer: Midlands Choice Commercial |
$165.90
|
| Rate for Payer: United Healthcare Commercial |
$213.30
|
|
|
XR Spine Scoliosis Study Standing
|
Facility
IP
|
$176.00
|
|
|
Service Code
|
CPT 72083
|
| Hospital Charge Code |
1170478
|
|
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 Spine Scoliosis Study Standing
|
Facility
OP
|
$176.00
|
|
|
Service Code
|
CPT 72083
|
| Hospital Charge Code |
1170478
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine Single View Specify Level
|
Facility
IP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170482
|
|
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 Single View Specify Level
|
Facility
OP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170482
|
|
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 Thoracic 2 Views
|
Facility
OP
|
$176.00
|
|
|
Service Code
|
CPT 72070
|
| Hospital Charge Code |
1170484
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Spine Thoracic 2 Views
|
Facility
IP
|
$176.00
|
|
|
Service Code
|
CPT 72070
|
| Hospital Charge Code |
1170484
|
|
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 Spine Thoracic 3 Views
|
Facility
IP
|
$202.00
|
|
|
Service Code
|
CPT 72072
|
| Hospital Charge Code |
1170486
|
|
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 Spine Thoracic 3 Views
|
Facility
OP
|
$202.00
|
|
|
Service Code
|
CPT 72072
|
| Hospital Charge Code |
1170486
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| 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 |
$101.95
|
| Rate for Payer: Amerigroup Medicare |
$102.01
|
| Rate for Payer: Cash Price |
$161.60
|
| 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 |
$101.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.96
|
| Rate for Payer: Medical Associates Commercial |
$151.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$101.00
|
| Rate for Payer: Midlands Choice Commercial |
$141.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$151.50
|
| Rate for Payer: United Healthcare Commercial |
$181.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$119.18
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Sternoclavicular Joint(s)
|
Facility
OP
|
$192.00
|
|
|
Service Code
|
CPT 71130
|
| Hospital Charge Code |
1170494
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna of IA Commercial |
$172.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$172.80
|
| Rate for Payer: Aetna of IA Medicare |
$109.44
|
| Rate for Payer: Amerigroup Medicaid |
$96.90
|
| Rate for Payer: Amerigroup Medicare |
$96.96
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$144.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$96.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$95.96
|
| Rate for Payer: Medical Associates Commercial |
$144.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$96.00
|
| Rate for Payer: Midlands Choice Commercial |
$134.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$97.44
|
| Rate for Payer: Partners Health Alliance Commercial |
$144.00
|
| Rate for Payer: United Healthcare Commercial |
$172.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$113.28
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Sternoclavicular Joint(s)
|
Facility
IP
|
$192.00
|
|
|
Service Code
|
CPT 71130
|
| Hospital Charge Code |
1170494
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna of IA Commercial |
$172.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$172.80
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$144.00
|
| Rate for Payer: Medical Associates Commercial |
$144.00
|
| Rate for Payer: Midlands Choice Commercial |
$134.40
|
| Rate for Payer: United Healthcare Commercial |
$172.80
|
|
|
XR Sternum Minimum 2 Views
|
Facility
OP
|
$180.00
|
|
|
Service Code
|
CPT 71120
|
| Hospital Charge Code |
1170496
|
|
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 Sternum Minimum 2 Views
|
Facility
IP
|
$180.00
|
|
|
Service Code
|
CPT 71120
|
| Hospital Charge Code |
1170496
|
|
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 Swallowing Function w/ Video
|
Facility
OP
|
$389.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
1170500
|
|
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 Swallowing Function w/ Video
|
Facility
IP
|
$389.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
1170500
|
|
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 Tibia/Fibula Left
|
Facility
IP
|
$146.00
|
|
|
Service Code
|
CPT 73590 LT
|
| Hospital Charge Code |
1170516
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
XR Tibia/Fibula Left
|
Facility
OP
|
$146.00
|
|
|
Service Code
|
CPT 73590 LT
|
| Hospital Charge Code |
1170516
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.97 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$73.69
|
| Rate for Payer: Amerigroup Medicare |
$73.73
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.97
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.00
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.50
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
|
|
XR Tibia/Fibula Right
|
Facility
IP
|
$146.00
|
|
|
Service Code
|
CPT 73590 RT
|
| Hospital Charge Code |
1170518
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
