|
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 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: 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 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 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: Molina Healthcare Managed Medicare |
$78.62
|
| Rate for Payer: Oscar Health of IA Commercial |
$116.25
|
| 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 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 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: Molina Healthcare Managed Medicare |
$110.06
|
| Rate for Payer: Oscar Health of IA Commercial |
$162.75
|
| 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 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: Molina Healthcare Managed Medicare |
$110.06
|
| Rate for Payer: Oscar Health of IA Commercial |
$162.75
|
| 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 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 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 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: Molina Healthcare Managed Medicare |
$150.64
|
| Rate for Payer: Oscar Health of IA Commercial |
$222.75
|
| 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 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: Molina Healthcare Managed Medicare |
$145.57
|
| Rate for Payer: Oscar Health of IA Commercial |
$215.25
|
| 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: 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
|
| 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: Molina Healthcare Managed Medicare |
$120.21
|
| Rate for Payer: Oscar Health of IA Commercial |
$177.75
|
| 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
|
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: 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
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
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 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: 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 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 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: 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
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
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: 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
|
| 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
|
|
