|
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
|
|
|
XR Sinuses Paranasal < 3 Views
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
1170432
|
|
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 Sinuses Paranasal < 3 Views
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
1170432
|
|
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 Sinuses Paranasal Complete
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
1170434
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Sinuses Paranasal Complete
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
1170434
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
XR Skull < 4 Views
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 70250
|
| Hospital Charge Code |
1170436
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Skull < 4 Views
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 70250
|
| Hospital Charge Code |
1170436
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
|
|
XR Skull Complete
|
Facility
|
OP
|
$268.00
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
1170438
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$103.51 |
| Max. Negotiated Rate |
$241.20 |
| Rate for Payer: Aetna of IA Commercial |
$241.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$241.20
|
| Rate for Payer: Aetna of IA Medicare |
$152.76
|
| Rate for Payer: Amerigroup Medicaid |
$154.58
|
| Rate for Payer: Amerigroup Medicare |
$121.81
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$201.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$120.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$153.08
|
| Rate for Payer: Medical Associates Commercial |
$201.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$120.60
|
| Rate for Payer: Midlands Choice Commercial |
$187.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$155.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$138.69
|
| Rate for Payer: United Healthcare Commercial |
$241.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$158.12
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Skull Complete
|
Facility
|
IP
|
$268.00
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
1170438
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$187.60 |
| Max. Negotiated Rate |
$241.20 |
| Rate for Payer: Aetna of IA Commercial |
$241.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$241.20
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$201.00
|
| Rate for Payer: Medical Associates Commercial |
$201.00
|
| Rate for Payer: Midlands Choice Commercial |
$187.60
|
| Rate for Payer: United Healthcare Commercial |
$241.20
|
|
|
XR Small Bowel w/ Serial Films
|
Facility
|
OP
|
$437.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
1170442
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$196.65 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of IA Commercial |
$393.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$393.30
|
| Rate for Payer: Aetna of IA Medicare |
$249.09
|
| Rate for Payer: Amerigroup Medicaid |
$252.06
|
| Rate for Payer: Amerigroup Medicare |
$198.62
|
| Rate for Payer: Cash Price |
$349.60
|
| Rate for Payer: Cash Price |
$349.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$327.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$196.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$249.61
|
| Rate for Payer: Medical Associates Commercial |
$327.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$196.65
|
| Rate for Payer: Midlands Choice Commercial |
$305.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$253.29
|
| Rate for Payer: Partners Health Alliance Commercial |
$226.15
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$257.83
|
| Rate for Payer: Wellmark IA HMO WHPI |
$298.49
|
| Rate for Payer: Wellmark IA PPO |
$328.80
|
|
|
XR Small Bowel w/ Serial Films
|
Facility
|
IP
|
$437.00
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
1170442
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$305.90 |
| Max. Negotiated Rate |
$393.30 |
| Rate for Payer: Aetna of IA Commercial |
$393.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$393.30
|
| Rate for Payer: Cash Price |
$349.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$327.75
|
| Rate for Payer: Medical Associates Commercial |
$327.75
|
| Rate for Payer: Midlands Choice Commercial |
$305.90
|
| Rate for Payer: United Healthcare Commercial |
$393.30
|
|
|
XR Speech Evaluation Dyname Pharyngeal
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
1170444
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$272.30 |
| Max. Negotiated Rate |
$350.10 |
| Rate for Payer: Aetna of IA Commercial |
$350.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$350.10
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$291.75
|
| Rate for Payer: Medical Associates Commercial |
$291.75
|
| Rate for Payer: Midlands Choice Commercial |
$272.30
|
| Rate for Payer: United Healthcare Commercial |
$350.10
|
|
|
XR Speech Evaluation Dyname Pharyngeal
|
Facility
|
OP
|
$389.00
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
1170444
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$175.05 |
| Max. Negotiated Rate |
$350.10 |
| Rate for Payer: Aetna of IA Commercial |
$350.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$350.10
|
| Rate for Payer: Aetna of IA Medicare |
$221.73
|
| Rate for Payer: Amerigroup Medicaid |
$224.38
|
| Rate for Payer: Amerigroup Medicare |
$176.80
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$291.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$175.05
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$222.20
|
| Rate for Payer: Medical Associates Commercial |
$291.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$175.05
|
| Rate for Payer: Midlands Choice Commercial |
$272.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$225.46
|
| Rate for Payer: Partners Health Alliance Commercial |
$201.31
|
| Rate for Payer: United Healthcare Commercial |
$350.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$229.51
|
| Rate for Payer: Wellmark IA HMO WHPI |
$298.49
|
| Rate for Payer: Wellmark IA PPO |
$328.80
|
|
|
XR Spine 1 View Cervical
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170446
|
|
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 Spine 1 View Cervical
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170446
|
|
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 Lumbar
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170448
|
|
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 Spine 1 View Lumbar
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
1170448
|
|
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
|
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 |
$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 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 |
$69.75 |
| 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 |
$89.40
|
| Rate for Payer: Amerigroup Medicare |
$70.45
|
| 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 |
$69.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$88.54
|
| Rate for Payer: Medical Associates Commercial |
$116.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$69.75
|
| Rate for Payer: Midlands Choice Commercial |
$108.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$89.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$80.21
|
| Rate for Payer: United Healthcare Commercial |
$139.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$91.45
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 Comp w/ Obliques
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 72050
|
| Hospital Charge Code |
1170454
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$97.65 |
| 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 |
$125.17
|
| Rate for Payer: Amerigroup Medicare |
$98.63
|
| 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 |
$97.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$123.95
|
| Rate for Payer: Medical Associates Commercial |
$162.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$97.65
|
| Rate for Payer: Midlands Choice Commercial |
$151.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$125.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.30
|
| Rate for Payer: United Healthcare Commercial |
$195.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$128.03
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 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 Minimum 4 Views
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 72050
|
| Hospital Charge Code |
1170461
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$97.65 |
| 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 |
$125.17
|
| Rate for Payer: Amerigroup Medicare |
$98.63
|
| 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 |
$97.65
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$123.95
|
| Rate for Payer: Medical Associates Commercial |
$162.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$97.65
|
| Rate for Payer: Midlands Choice Commercial |
$151.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$125.77
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.30
|
| Rate for Payer: United Healthcare Commercial |
$195.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$128.03
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
