|
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 Complete Minimum 3 Views
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
1170353
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.35 |
| 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 |
$94.02
|
| Rate for Payer: Amerigroup Medicare |
$74.08
|
| 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 |
$73.35
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$93.11
|
| Rate for Payer: Medical Associates Commercial |
$122.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.35
|
| Rate for Payer: Midlands Choice Commercial |
$114.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$94.47
|
| Rate for Payer: Partners Health Alliance Commercial |
$84.35
|
| Rate for Payer: United Healthcare Commercial |
$146.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$96.17
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$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 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 |
$90.90 |
| 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 |
$116.51
|
| Rate for Payer: Amerigroup Medicare |
$91.81
|
| 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 |
$90.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$115.38
|
| Rate for Payer: Medical Associates Commercial |
$151.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.90
|
| Rate for Payer: Midlands Choice Commercial |
$141.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$117.08
|
| Rate for Payer: Partners Health Alliance Commercial |
$104.54
|
| Rate for Payer: United Healthcare Commercial |
$181.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$119.18
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 Left
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 71100 LT
|
| Hospital Charge Code |
1170371
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$66.15 |
| 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 |
$84.79
|
| Rate for Payer: Amerigroup Medicare |
$66.81
|
| Rate for Payer: Cash Price |
$117.60
|
| 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 |
$66.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$83.97
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$66.15
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$85.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$76.07
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.73
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$66.15 |
| 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 |
$84.79
|
| Rate for Payer: Amerigroup Medicare |
$66.81
|
| Rate for Payer: Cash Price |
$117.60
|
| 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 |
$66.15
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$83.97
|
| Rate for Payer: Medical Associates Commercial |
$110.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$66.15
|
| Rate for Payer: Midlands Choice Commercial |
$102.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$85.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$76.07
|
| Rate for Payer: United Healthcare Commercial |
$132.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.73
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 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 Sacroiliac Joints Minimum 3 Views
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
CPT 72202
|
| Hospital Charge Code |
1170387
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$90.45 |
| 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 |
$115.94
|
| Rate for Payer: Amerigroup Medicare |
$91.35
|
| 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 |
$90.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$114.81
|
| Rate for Payer: Medical Associates Commercial |
$150.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.45
|
| Rate for Payer: Midlands Choice Commercial |
$140.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$116.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$104.02
|
| Rate for Payer: United Healthcare Commercial |
$180.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$118.59
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$90.45 |
| 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 |
$115.94
|
| Rate for Payer: Amerigroup Medicare |
$91.35
|
| 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 |
$90.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$114.81
|
| Rate for Payer: Medical Associates Commercial |
$150.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.45
|
| Rate for Payer: Midlands Choice Commercial |
$140.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$116.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$104.02
|
| Rate for Payer: United Healthcare Commercial |
$180.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$118.59
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$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 Scapula Right
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 73010 RT
|
| Hospital Charge Code |
1170403
|
|
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 Right
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 73010 RT
|
| Hospital Charge Code |
1170403
|
|
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 Shoulder 1 View Left
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 73020 LT
|
| Hospital Charge Code |
1170409
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$67.95 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Aetna of IA Medicare |
$86.07
|
| Rate for Payer: Amerigroup Medicaid |
$87.10
|
| Rate for Payer: Amerigroup Medicare |
$68.63
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$86.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.95
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$87.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$78.14
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$89.09
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Shoulder 1 View Left
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 73020 LT
|
| Hospital Charge Code |
1170409
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
|
|
XR Shoulder 1 View Right
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 73020 RT
|
| Hospital Charge Code |
1170411
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$67.95 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Aetna of IA Medicare |
$86.07
|
| Rate for Payer: Amerigroup Medicaid |
$87.10
|
| Rate for Payer: Amerigroup Medicare |
$68.63
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.95
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$86.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.95
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$87.52
|
| Rate for Payer: Partners Health Alliance Commercial |
$78.14
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$89.09
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Shoulder 1 View Right
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 73020 RT
|
| Hospital Charge Code |
1170411
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
|
|
XR Shoulder Complete Left
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 73030 LT
|
| Hospital Charge Code |
1170415
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
|
|
XR Shoulder Complete Left
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
CPT 73030 LT
|
| Hospital Charge Code |
1170415
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$66.60 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Aetna of IA Medicare |
$84.36
|
| Rate for Payer: Amerigroup Medicaid |
$85.37
|
| Rate for Payer: Amerigroup Medicare |
$67.27
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$66.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$84.54
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$66.60
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$85.78
|
| Rate for Payer: Partners Health Alliance Commercial |
$76.59
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$87.32
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Shoulder Complete Right
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
CPT 73030 RT
|
| Hospital Charge Code |
1170417
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna of IA Commercial |
$133.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.00
|
| Rate for Payer: Medical Associates Commercial |
$111.00
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: United Healthcare Commercial |
$133.20
|
|
