|
XR Ankle 2 Views Right
|
Facility
OP
|
$133.00
|
|
|
Service Code
|
CPT 73600 RT
|
| Hospital Charge Code |
1169938
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$66.47 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of IA Commercial |
$119.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$119.70
|
| Rate for Payer: Aetna of IA Medicare |
$75.81
|
| Rate for Payer: Amerigroup Medicaid |
$67.13
|
| Rate for Payer: Amerigroup Medicare |
$67.16
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$99.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$66.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$66.47
|
| Rate for Payer: Medical Associates Commercial |
$99.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$66.50
|
| Rate for Payer: Midlands Choice Commercial |
$93.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$67.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$99.75
|
| Rate for Payer: United Healthcare Commercial |
$119.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$78.47
|
|
|
XR Ankle Complete Left
|
Facility
IP
|
$146.00
|
|
|
Service Code
|
CPT 73610 LT
|
| Hospital Charge Code |
1169942
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
XR Ankle Complete Left
|
Facility
OP
|
$146.00
|
|
|
Service Code
|
CPT 73610 LT
|
| Hospital Charge Code |
1169942
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.97 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$73.69
|
| Rate for Payer: Amerigroup Medicare |
$73.73
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.97
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.00
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.50
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
|
|
XR Ankle Complete Right
|
Facility
IP
|
$146.00
|
|
|
Service Code
|
CPT 73610 RT
|
| Hospital Charge Code |
1169944
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
XR Ankle Complete Right
|
Facility
OP
|
$146.00
|
|
|
Service Code
|
CPT 73610 RT
|
| Hospital Charge Code |
1169944
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.97 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$73.69
|
| Rate for Payer: Amerigroup Medicare |
$73.73
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.97
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.00
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.50
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
|
|
XR Arthrogram Knee Left
|
Facility
OP
|
$723.00
|
|
|
Service Code
|
CPT 73580 LT
|
| Hospital Charge Code |
1169970
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$361.36 |
| Max. Negotiated Rate |
$650.70 |
| Rate for Payer: Aetna of IA Commercial |
$650.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$650.70
|
| Rate for Payer: Aetna of IA Medicare |
$412.11
|
| Rate for Payer: Amerigroup Medicaid |
$364.90
|
| Rate for Payer: Amerigroup Medicare |
$365.12
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$542.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$361.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$361.36
|
| Rate for Payer: Medical Associates Commercial |
$542.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$361.50
|
| Rate for Payer: Midlands Choice Commercial |
$506.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$366.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$542.25
|
| Rate for Payer: United Healthcare Commercial |
$650.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$426.57
|
|
|
XR Arthrogram Knee Left
|
Facility
IP
|
$723.00
|
|
|
Service Code
|
CPT 73580 LT
|
| Hospital Charge Code |
1169970
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$506.10 |
| Max. Negotiated Rate |
$650.70 |
| Rate for Payer: Aetna of IA Commercial |
$650.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$650.70
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$542.25
|
| Rate for Payer: Medical Associates Commercial |
$542.25
|
| Rate for Payer: Midlands Choice Commercial |
$506.10
|
| Rate for Payer: United Healthcare Commercial |
$650.70
|
|
|
XR Arthrogram Knee Right
|
Facility
IP
|
$723.00
|
|
|
Service Code
|
CPT 73580 RT
|
| Hospital Charge Code |
1169972
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$506.10 |
| Max. Negotiated Rate |
$650.70 |
| Rate for Payer: Aetna of IA Commercial |
$650.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$650.70
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$542.25
|
| Rate for Payer: Medical Associates Commercial |
$542.25
|
| Rate for Payer: Midlands Choice Commercial |
$506.10
|
| Rate for Payer: United Healthcare Commercial |
$650.70
|
|
|
XR Arthrogram Knee Right
|
Facility
OP
|
$723.00
|
|
|
Service Code
|
CPT 73580 RT
|
| Hospital Charge Code |
1169972
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$361.36 |
| Max. Negotiated Rate |
$650.70 |
| Rate for Payer: Aetna of IA Commercial |
$650.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$650.70
|
| Rate for Payer: Aetna of IA Medicare |
$412.11
|
| Rate for Payer: Amerigroup Medicaid |
$364.90
|
| Rate for Payer: Amerigroup Medicare |
$365.12
|
| Rate for Payer: Cash Price |
$578.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$542.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$361.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$361.36
|
| Rate for Payer: Medical Associates Commercial |
$542.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$361.50
|
| Rate for Payer: Midlands Choice Commercial |
$506.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$366.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$542.25
|
| Rate for Payer: United Healthcare Commercial |
$650.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$426.57
|
|
|
XR Arthrogram Shoulder Left
|
Facility
OP
|
$772.00
|
|
|
Service Code
|
CPT 73040 LT
|
| Hospital Charge Code |
1169984
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$385.85 |
| Max. Negotiated Rate |
$694.80 |
| Rate for Payer: Aetna of IA Commercial |
$694.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$694.80
|
| Rate for Payer: Aetna of IA Medicare |
$440.04
|
| Rate for Payer: Amerigroup Medicaid |
$389.63
|
| Rate for Payer: Amerigroup Medicare |
$389.86
|
| Rate for Payer: Cash Price |
$617.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$579.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$386.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$385.85
|
| Rate for Payer: Medical Associates Commercial |
$579.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$386.00
|
| Rate for Payer: Midlands Choice Commercial |
$540.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$391.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$579.00
|
| Rate for Payer: United Healthcare Commercial |
$694.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$455.48
|
|
|
XR Arthrogram Shoulder Left
|
Facility
IP
|
$772.00
|
|
|
Service Code
|
CPT 73040 LT
|
| Hospital Charge Code |
1169984
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$540.40 |
| Max. Negotiated Rate |
$694.80 |
| Rate for Payer: Aetna of IA Commercial |
$694.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$694.80
|
| Rate for Payer: Cash Price |
$617.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$579.00
|
| Rate for Payer: Medical Associates Commercial |
$579.00
|
| Rate for Payer: Midlands Choice Commercial |
$540.40
|
| Rate for Payer: United Healthcare Commercial |
$694.80
|
|
|
XR Arthrogram Shoulder Right
|
Facility
IP
|
$772.00
|
|
|
Service Code
|
CPT 73040 RT
|
| Hospital Charge Code |
1169986
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$540.40 |
| Max. Negotiated Rate |
$694.80 |
| Rate for Payer: Aetna of IA Commercial |
$694.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$694.80
|
| Rate for Payer: Cash Price |
$617.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$579.00
|
| Rate for Payer: Medical Associates Commercial |
$579.00
|
| Rate for Payer: Midlands Choice Commercial |
$540.40
|
| Rate for Payer: United Healthcare Commercial |
$694.80
|
|
|
XR Arthrogram Shoulder Right
|
Facility
OP
|
$772.00
|
|
|
Service Code
|
CPT 73040 RT
|
| Hospital Charge Code |
1169986
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$385.85 |
| Max. Negotiated Rate |
$694.80 |
| Rate for Payer: Aetna of IA Commercial |
$694.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$694.80
|
| Rate for Payer: Aetna of IA Medicare |
$440.04
|
| Rate for Payer: Amerigroup Medicaid |
$389.63
|
| Rate for Payer: Amerigroup Medicare |
$389.86
|
| Rate for Payer: Cash Price |
$617.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$579.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$386.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$385.85
|
| Rate for Payer: Medical Associates Commercial |
$579.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$386.00
|
| Rate for Payer: Midlands Choice Commercial |
$540.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$391.79
|
| Rate for Payer: Partners Health Alliance Commercial |
$579.00
|
| Rate for Payer: United Healthcare Commercial |
$694.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$455.48
|
|
|
XR Arthrogram Wrist Left
|
Facility
OP
|
$759.00
|
|
|
Service Code
|
CPT 73115 LT
|
| Hospital Charge Code |
1169996
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$379.35 |
| Max. Negotiated Rate |
$683.10 |
| Rate for Payer: Aetna of IA Commercial |
$683.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$683.10
|
| Rate for Payer: Aetna of IA Medicare |
$432.63
|
| Rate for Payer: Amerigroup Medicaid |
$383.07
|
| Rate for Payer: Amerigroup Medicare |
$383.30
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$569.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$379.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$379.35
|
| Rate for Payer: Medical Associates Commercial |
$569.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$379.50
|
| Rate for Payer: Midlands Choice Commercial |
$531.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$385.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$569.25
|
| Rate for Payer: United Healthcare Commercial |
$683.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$447.81
|
|
|
XR Arthrogram Wrist Left
|
Facility
IP
|
$759.00
|
|
|
Service Code
|
CPT 73115 LT
|
| Hospital Charge Code |
1169996
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$531.30 |
| Max. Negotiated Rate |
$683.10 |
| Rate for Payer: Aetna of IA Commercial |
$683.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$683.10
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$569.25
|
| Rate for Payer: Medical Associates Commercial |
$569.25
|
| Rate for Payer: Midlands Choice Commercial |
$531.30
|
| Rate for Payer: United Healthcare Commercial |
$683.10
|
|
|
XR Arthrogram Wrist Right
|
Facility
IP
|
$759.00
|
|
|
Service Code
|
CPT 73115 RT
|
| Hospital Charge Code |
1169998
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$531.30 |
| Max. Negotiated Rate |
$683.10 |
| Rate for Payer: Aetna of IA Commercial |
$683.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$683.10
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$569.25
|
| Rate for Payer: Medical Associates Commercial |
$569.25
|
| Rate for Payer: Midlands Choice Commercial |
$531.30
|
| Rate for Payer: United Healthcare Commercial |
$683.10
|
|
|
XR Arthrogram Wrist Right
|
Facility
OP
|
$759.00
|
|
|
Service Code
|
CPT 73115 RT
|
| Hospital Charge Code |
1169998
|
|
Hospital Revenue Code
|
322
|
| Min. Negotiated Rate |
$379.35 |
| Max. Negotiated Rate |
$683.10 |
| Rate for Payer: Aetna of IA Commercial |
$683.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$683.10
|
| Rate for Payer: Aetna of IA Medicare |
$432.63
|
| Rate for Payer: Amerigroup Medicaid |
$383.07
|
| Rate for Payer: Amerigroup Medicare |
$383.30
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$569.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$379.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$379.35
|
| Rate for Payer: Medical Associates Commercial |
$569.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$379.50
|
| Rate for Payer: Midlands Choice Commercial |
$531.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$385.19
|
| Rate for Payer: Partners Health Alliance Commercial |
$569.25
|
| Rate for Payer: United Healthcare Commercial |
$683.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$447.81
|
|
|
XR Barium Enema Complete
|
Facility
OP
|
$474.00
|
|
|
Service Code
|
CPT 74270
|
| Hospital Charge Code |
1170002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$178.56 |
| Max. Negotiated Rate |
$426.60 |
| Rate for Payer: Aetna of IA Commercial |
$426.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$426.60
|
| Rate for Payer: Aetna of IA Medicare |
$270.18
|
| Rate for Payer: Amerigroup Medicaid |
$239.23
|
| Rate for Payer: Amerigroup Medicare |
$239.37
|
| Rate for Payer: Cash Price |
$379.20
|
| Rate for Payer: Cash Price |
$379.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$355.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$237.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$236.91
|
| Rate for Payer: Medical Associates Commercial |
$355.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$237.00
|
| Rate for Payer: Midlands Choice Commercial |
$331.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$240.56
|
| Rate for Payer: Partners Health Alliance Commercial |
$355.50
|
| Rate for Payer: United Healthcare Commercial |
$426.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$279.66
|
| Rate for Payer: Wellmark IA HMO |
$178.56
|
| Rate for Payer: Wellmark IA PPO |
$196.42
|
|
|
XR Barium Enema Complete
|
Facility
IP
|
$474.00
|
|
|
Service Code
|
CPT 74270
|
| Hospital Charge Code |
1170002
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$331.80 |
| Max. Negotiated Rate |
$426.60 |
| Rate for Payer: Aetna of IA Commercial |
$426.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$426.60
|
| Rate for Payer: Cash Price |
$379.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$355.50
|
| Rate for Payer: Medical Associates Commercial |
$355.50
|
| Rate for Payer: Midlands Choice Commercial |
$331.80
|
| Rate for Payer: United Healthcare Commercial |
$426.60
|
|
|
XR Barium Enema w/ Air Complete
|
Facility
OP
|
$547.00
|
|
|
Service Code
|
CPT 74280
|
| Hospital Charge Code |
1170006
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$178.56 |
| Max. Negotiated Rate |
$492.30 |
| Rate for Payer: Aetna of IA Commercial |
$492.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$492.30
|
| Rate for Payer: Aetna of IA Medicare |
$311.79
|
| Rate for Payer: Amerigroup Medicaid |
$276.07
|
| Rate for Payer: Amerigroup Medicare |
$276.24
|
| Rate for Payer: Cash Price |
$437.60
|
| Rate for Payer: Cash Price |
$437.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$410.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$273.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$273.39
|
| Rate for Payer: Medical Associates Commercial |
$410.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$273.50
|
| Rate for Payer: Midlands Choice Commercial |
$382.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$277.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$410.25
|
| Rate for Payer: United Healthcare Commercial |
$492.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$322.73
|
| Rate for Payer: Wellmark IA HMO |
$178.56
|
| Rate for Payer: Wellmark IA PPO |
$196.42
|
|
|
XR Barium Enema w/ Air Complete
|
Facility
IP
|
$547.00
|
|
|
Service Code
|
CPT 74280
|
| Hospital Charge Code |
1170006
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$382.90 |
| Max. Negotiated Rate |
$492.30 |
| Rate for Payer: Aetna of IA Commercial |
$492.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$492.30
|
| Rate for Payer: Cash Price |
$437.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$410.25
|
| Rate for Payer: Medical Associates Commercial |
$410.25
|
| Rate for Payer: Midlands Choice Commercial |
$382.90
|
| Rate for Payer: United Healthcare Commercial |
$492.30
|
|
|
XR Bone Age Studies
|
Facility
OP
|
$134.00
|
|
|
Service Code
|
CPT 77072
|
| Hospital Charge Code |
1170014
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$120.60 |
| Rate for Payer: Aetna of IA Commercial |
$120.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$120.60
|
| Rate for Payer: Aetna of IA Medicare |
$76.38
|
| Rate for Payer: Amerigroup Medicaid |
$67.63
|
| Rate for Payer: Amerigroup Medicare |
$67.67
|
| Rate for Payer: Cash Price |
$107.20
|
| Rate for Payer: Cash Price |
$107.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$100.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$67.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$66.97
|
| Rate for Payer: Medical Associates Commercial |
$100.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$67.00
|
| Rate for Payer: Midlands Choice Commercial |
$93.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$100.50
|
| Rate for Payer: United Healthcare Commercial |
$120.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$79.06
|
| Rate for Payer: Wellmark IA HMO |
$59.52
|
| Rate for Payer: Wellmark IA PPO |
$65.47
|
|
|
XR Bone Age Studies
|
Facility
IP
|
$134.00
|
|
|
Service Code
|
CPT 77072
|
| Hospital Charge Code |
1170014
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$93.80 |
| Max. Negotiated Rate |
$120.60 |
| Rate for Payer: Aetna of IA Commercial |
$120.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$120.60
|
| Rate for Payer: Cash Price |
$107.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$100.50
|
| Rate for Payer: Medical Associates Commercial |
$100.50
|
| Rate for Payer: Midlands Choice Commercial |
$93.80
|
| Rate for Payer: United Healthcare Commercial |
$120.60
|
|
|
XR Bone Survey Complete (Mets)
|
Facility
IP
|
$552.00
|
|
|
Service Code
|
CPT 77075
|
| Hospital Charge Code |
1170018
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$386.40 |
| Max. Negotiated Rate |
$496.80 |
| Rate for Payer: Aetna of IA Commercial |
$496.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$496.80
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$414.00
|
| Rate for Payer: Medical Associates Commercial |
$414.00
|
| Rate for Payer: Midlands Choice Commercial |
$386.40
|
| Rate for Payer: United Healthcare Commercial |
$496.80
|
|
|
XR Bone Survey Complete (Mets)
|
Facility
OP
|
$552.00
|
|
|
Service Code
|
CPT 77075
|
| Hospital Charge Code |
1170018
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$178.56 |
| Max. Negotiated Rate |
$496.80 |
| Rate for Payer: Aetna of IA Commercial |
$496.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$496.80
|
| Rate for Payer: Aetna of IA Medicare |
$314.64
|
| Rate for Payer: Amerigroup Medicaid |
$278.59
|
| Rate for Payer: Amerigroup Medicare |
$278.76
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$414.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$276.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$275.89
|
| Rate for Payer: Medical Associates Commercial |
$414.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$276.00
|
| Rate for Payer: Midlands Choice Commercial |
$386.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$280.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$414.00
|
| Rate for Payer: United Healthcare Commercial |
$496.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$325.68
|
| Rate for Payer: Wellmark IA HMO |
$178.56
|
| Rate for Payer: Wellmark IA PPO |
$196.42
|
|
