|
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: Molina Healthcare Managed Medicare |
$115.13
|
| Rate for Payer: Oscar Health of IA Commercial |
$170.25
|
| 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
|
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: Molina Healthcare Managed Medicare |
$115.13
|
| Rate for Payer: Oscar Health of IA Commercial |
$170.25
|
| 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 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 |
$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: Molina Healthcare Managed Medicare |
$115.13
|
| Rate for Payer: Oscar Health of IA Commercial |
$170.25
|
| 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 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: Molina Healthcare Managed Medicare |
$76.08
|
| Rate for Payer: Oscar Health of IA Commercial |
$112.50
|
| 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
|
|
|
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 |
$59.52 |
| 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 |
$82.27
|
| Rate for Payer: Amerigroup Medicare |
$82.32
|
| Rate for Payer: Cash Price |
$130.40
|
| 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 |
$81.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$81.47
|
| Rate for Payer: Medical Associates Commercial |
$122.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.50
|
| Rate for Payer: Midlands Choice Commercial |
$114.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$82.72
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$82.67
|
| Rate for Payer: Oscar Health of IA Commercial |
$122.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$122.25
|
| Rate for Payer: United Healthcare Commercial |
$146.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$96.17
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
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 + 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 |
$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: Molina Healthcare Managed Medicare |
$89.27
|
| Rate for Payer: Oscar Health of IA Commercial |
$132.00
|
| 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 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 |
$100.96 |
| 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: 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: Molina Healthcare Managed Medicare |
$102.45
|
| Rate for Payer: Oscar Health of IA Commercial |
$151.50
|
| 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
|
|
|
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 |
$73.47 |
| 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 |
$74.19
|
| Rate for Payer: Amerigroup Medicare |
$74.24
|
| 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 |
$73.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.47
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.60
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$74.56
|
| Rate for Payer: Oscar Health of IA Commercial |
$110.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$110.25
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.73
|
|
|
XR Ribs 2 Views Left
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
CPT 71100 LT
|
| Hospital Charge Code |
1170371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.90 |
| 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: Cash Price |
$117.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$110.25
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
|
|
XR Ribs 2 Views Right
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
CPT 71100 RT
|
| Hospital Charge Code |
1170373
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.90 |
| 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: Cash Price |
$117.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$110.25
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
|
|
XR Ribs 2 Views Right
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 71100 RT
|
| Hospital Charge Code |
1170373
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.47 |
| 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 |
$74.19
|
| Rate for Payer: Amerigroup Medicare |
$74.24
|
| 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 |
$73.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.47
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.60
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$74.56
|
| Rate for Payer: Oscar Health of IA Commercial |
$110.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$110.25
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.73
|
|
|
XR Sacroiliac Joints Minimum 3 Views
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
CPT 72202
|
| Hospital Charge Code |
1170387
|
|
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: Molina Healthcare Managed Medicare |
$101.95
|
| Rate for Payer: Oscar Health of IA Commercial |
$150.75
|
| 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 Sacroiliac Joints Minimum 3 Views
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
CPT 72202
|
| Hospital Charge Code |
1170387
|
|
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 Sacrum/Coccyx Minimum 2 Views
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
CPT 72220
|
| Hospital Charge Code |
1170391
|
|
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 Sacrum/Coccyx Minimum 2 Views
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
CPT 72220
|
| Hospital Charge Code |
1170391
|
|
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: Molina Healthcare Managed Medicare |
$101.95
|
| Rate for Payer: Oscar Health of IA Commercial |
$150.75
|
| 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 Scapula Left
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 73010 LT
|
| Hospital Charge Code |
1170401
|
|
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 Scapula Left
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 73010 LT
|
| Hospital Charge Code |
1170401
|
|
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: Molina Healthcare Managed Medicare |
$89.27
|
| Rate for Payer: Oscar Health of IA Commercial |
$132.00
|
| 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 Scapula Right
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 73010 RT
|
| Hospital Charge Code |
1170403
|
|
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: Molina Healthcare Managed Medicare |
$89.27
|
| Rate for Payer: Oscar Health of IA Commercial |
$132.00
|
| 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
|
|
