|
XR Bone Survey Infant
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
1170020
|
|
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 Bone Survey Infant
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
1170020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$79.20 |
| 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: Aetna of IA Medicare |
$100.32
|
| Rate for Payer: Amerigroup Medicaid |
$101.52
|
| Rate for Payer: Amerigroup Medicare |
$79.99
|
| 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 |
$79.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.53
|
| Rate for Payer: Medical Associates Commercial |
$132.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.20
|
| Rate for Payer: Midlands Choice Commercial |
$123.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.08
|
| Rate for Payer: United Healthcare Commercial |
$158.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.84
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Calcaneous Left
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
CPT 73650 LT
|
| Hospital Charge Code |
1170032
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of IA Commercial |
$114.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$114.30
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$95.25
|
| Rate for Payer: Medical Associates Commercial |
$95.25
|
| Rate for Payer: Midlands Choice Commercial |
$88.90
|
| Rate for Payer: United Healthcare Commercial |
$114.30
|
|
|
XR Calcaneous Left
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
CPT 73650 LT
|
| Hospital Charge Code |
1170032
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of IA Commercial |
$114.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$114.30
|
| Rate for Payer: Aetna of IA Medicare |
$72.39
|
| Rate for Payer: Amerigroup Medicaid |
$73.25
|
| Rate for Payer: Amerigroup Medicare |
$57.72
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$95.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.54
|
| Rate for Payer: Medical Associates Commercial |
$95.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.15
|
| Rate for Payer: Midlands Choice Commercial |
$88.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$73.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$65.72
|
| Rate for Payer: United Healthcare Commercial |
$114.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$74.93
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Calcaneous Right
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
CPT 73650 RT
|
| Hospital Charge Code |
1170034
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.15 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of IA Commercial |
$114.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$114.30
|
| Rate for Payer: Aetna of IA Medicare |
$72.39
|
| Rate for Payer: Amerigroup Medicaid |
$73.25
|
| Rate for Payer: Amerigroup Medicare |
$57.72
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$95.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.54
|
| Rate for Payer: Medical Associates Commercial |
$95.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.15
|
| Rate for Payer: Midlands Choice Commercial |
$88.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$73.61
|
| Rate for Payer: Partners Health Alliance Commercial |
$65.72
|
| Rate for Payer: United Healthcare Commercial |
$114.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$74.93
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Calcaneous Right
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
CPT 73650 RT
|
| Hospital Charge Code |
1170034
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of IA Commercial |
$114.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$114.30
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$95.25
|
| Rate for Payer: Medical Associates Commercial |
$95.25
|
| Rate for Payer: Midlands Choice Commercial |
$88.90
|
| Rate for Payer: United Healthcare Commercial |
$114.30
|
|
|
XR Chest 1 View
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 71045
|
| Hospital Charge Code |
1345763
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$51.75 |
| Max. Negotiated Rate |
$114.03 |
| Rate for Payer: Aetna of IA Commercial |
$103.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.50
|
| Rate for Payer: Aetna of IA Medicare |
$65.55
|
| Rate for Payer: Amerigroup Medicaid |
$66.33
|
| Rate for Payer: Amerigroup Medicare |
$52.27
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$51.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$65.69
|
| Rate for Payer: Medical Associates Commercial |
$86.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$51.75
|
| Rate for Payer: Midlands Choice Commercial |
$80.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$66.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$59.51
|
| Rate for Payer: United Healthcare Commercial |
$103.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.85
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Chest 1 View
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 71045
|
| Hospital Charge Code |
1345763
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$103.50 |
| Rate for Payer: Aetna of IA Commercial |
$103.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$103.50
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$86.25
|
| Rate for Payer: Medical Associates Commercial |
$86.25
|
| Rate for Payer: Midlands Choice Commercial |
$80.50
|
| Rate for Payer: United Healthcare Commercial |
$103.50
|
|
|
XR CHEST 2 VIEWS
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
CPT 71046
|
| Hospital Charge Code |
689607
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$151.20 |
| Rate for Payer: Aetna of IA Commercial |
$151.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$151.20
|
| Rate for Payer: Aetna of IA Medicare |
$95.76
|
| Rate for Payer: Amerigroup Medicaid |
$96.90
|
| Rate for Payer: Amerigroup Medicare |
$76.36
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$126.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$95.96
|
| Rate for Payer: Medical Associates Commercial |
$126.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.60
|
| Rate for Payer: Midlands Choice Commercial |
$117.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$97.37
|
| Rate for Payer: Partners Health Alliance Commercial |
$86.94
|
| Rate for Payer: United Healthcare Commercial |
$151.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$99.12
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR CHEST 2 VIEWS
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
CPT 71046
|
| Hospital Charge Code |
689607
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$117.60 |
| Max. Negotiated Rate |
$151.20 |
| Rate for Payer: Aetna of IA Commercial |
$151.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$151.20
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$126.00
|
| Rate for Payer: Medical Associates Commercial |
$126.00
|
| Rate for Payer: Midlands Choice Commercial |
$117.60
|
| Rate for Payer: United Healthcare Commercial |
$151.20
|
|
|
XR Chest 2 Views w/ Fluoroscopy
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
CPT 71023
|
| Hospital Charge Code |
1170042
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$80.55 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Aetna of IA Medicare |
$102.03
|
| Rate for Payer: Amerigroup Medicaid |
$103.25
|
| Rate for Payer: Amerigroup Medicare |
$81.36
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$80.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.24
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$80.55
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$103.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$92.63
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$105.61
|
|
|
XR Chest 2 Views w/ Fluoroscopy
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT 71023
|
| Hospital Charge Code |
1170042
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
|
|
XR Chest 2 Views w/ Obliques
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 71022
|
| Hospital Charge Code |
1170044
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$86.40 |
| 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: Aetna of IA Medicare |
$109.44
|
| Rate for Payer: Amerigroup Medicaid |
$110.75
|
| Rate for Payer: Amerigroup Medicare |
$87.26
|
| 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 |
$86.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$109.67
|
| Rate for Payer: Medical Associates Commercial |
$144.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$86.40
|
| Rate for Payer: Midlands Choice Commercial |
$134.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$111.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$99.36
|
| Rate for Payer: United Healthcare Commercial |
$172.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$113.28
|
|
|
XR Chest 2 Views w/ Obliques
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 71022
|
| Hospital Charge Code |
1170044
|
|
Hospital Revenue Code
|
324
|
| 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 CHEST 3 VIEWS
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 71047
|
| Hospital Charge Code |
1170040
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$86.40 |
| 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: Aetna of IA Medicare |
$109.44
|
| Rate for Payer: Amerigroup Medicaid |
$110.75
|
| Rate for Payer: Amerigroup Medicare |
$87.26
|
| 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 |
$86.40
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$109.67
|
| Rate for Payer: Medical Associates Commercial |
$144.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$86.40
|
| Rate for Payer: Midlands Choice Commercial |
$134.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$111.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$99.36
|
| Rate for Payer: United Healthcare Commercial |
$172.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$113.28
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR CHEST 3 VIEWS
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 71047
|
| Hospital Charge Code |
1170040
|
|
Hospital Revenue Code
|
324
|
| 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 Chest Decubitus Left
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 71035 LT
|
| Hospital Charge Code |
1170049
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$79.20 |
| 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: Aetna of IA Medicare |
$100.32
|
| Rate for Payer: Amerigroup Medicaid |
$101.52
|
| Rate for Payer: Amerigroup Medicare |
$79.99
|
| 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 |
$79.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.53
|
| Rate for Payer: Medical Associates Commercial |
$132.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.20
|
| Rate for Payer: Midlands Choice Commercial |
$123.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.08
|
| Rate for Payer: United Healthcare Commercial |
$158.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.84
|
|
|
XR Chest Decubitus Left
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 71035 LT
|
| Hospital Charge Code |
1170049
|
|
Hospital Revenue Code
|
324
|
| 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 Chest Decubitus Right
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 71035 RT
|
| Hospital Charge Code |
1170051
|
|
Hospital Revenue Code
|
324
|
| 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 Chest Decubitus Right
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 71035 RT
|
| Hospital Charge Code |
1170051
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$79.20 |
| 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: Aetna of IA Medicare |
$100.32
|
| Rate for Payer: Amerigroup Medicaid |
$101.52
|
| Rate for Payer: Amerigroup Medicare |
$79.99
|
| 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 |
$79.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.53
|
| Rate for Payer: Medical Associates Commercial |
$132.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.20
|
| Rate for Payer: Midlands Choice Commercial |
$123.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.08
|
| Rate for Payer: United Healthcare Commercial |
$158.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.84
|
|
|
XR CHEST MINIMUM 4 VIEWS
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 71048
|
| Hospital Charge Code |
1170053
|
|
Hospital Revenue Code
|
324
|
| 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 CHEST MINIMUM 4 VIEWS
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 71048
|
| Hospital Charge Code |
1170053
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$79.20 |
| 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: Aetna of IA Medicare |
$100.32
|
| Rate for Payer: Amerigroup Medicaid |
$101.52
|
| Rate for Payer: Amerigroup Medicare |
$79.99
|
| 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 |
$79.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$100.53
|
| Rate for Payer: Medical Associates Commercial |
$132.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$79.20
|
| Rate for Payer: Midlands Choice Commercial |
$123.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$102.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.08
|
| Rate for Payer: United Healthcare Commercial |
$158.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.84
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Cholangiogram in OR
|
Facility
|
IP
|
$830.00
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
1170065
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$581.00 |
| Max. Negotiated Rate |
$747.00 |
| Rate for Payer: Aetna of IA Commercial |
$747.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$747.00
|
| Rate for Payer: Cash Price |
$664.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$622.50
|
| Rate for Payer: Medical Associates Commercial |
$622.50
|
| Rate for Payer: Midlands Choice Commercial |
$581.00
|
| Rate for Payer: United Healthcare Commercial |
$747.00
|
|
|
XR Cholangiogram in OR
|
Facility
|
OP
|
$830.00
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
1170065
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$373.50 |
| Max. Negotiated Rate |
$747.00 |
| Rate for Payer: Aetna of IA Commercial |
$747.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$747.00
|
| Rate for Payer: Aetna of IA Medicare |
$473.10
|
| Rate for Payer: Amerigroup Medicaid |
$478.74
|
| Rate for Payer: Amerigroup Medicare |
$377.24
|
| Rate for Payer: Cash Price |
$664.00
|
| Rate for Payer: Cash Price |
$664.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$622.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$373.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$474.10
|
| Rate for Payer: Medical Associates Commercial |
$622.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$373.50
|
| Rate for Payer: Midlands Choice Commercial |
$581.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$481.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$429.52
|
| Rate for Payer: United Healthcare Commercial |
$747.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$489.70
|
| Rate for Payer: Wellmark IA HMO WHPI |
$463.69
|
| Rate for Payer: Wellmark IA PPO |
$510.77
|
|
|
XR Clavicle Left
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 73000 LT
|
| Hospital Charge Code |
1170075
|
|
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
|
|
