|
XR Hip Min 4 Views Lt w/ Pelvis
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 73503 LT
|
| Hospital Charge Code |
8025382
|
|
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: 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
|
|
|
XR Hip Min 4 Views Lt w/ Pelvis
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 73503 LT
|
| Hospital Charge Code |
8025382
|
|
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 Hip Min 4 Views Rt w/ Pelvis
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 73503 RT
|
| Hospital Charge Code |
8025385
|
|
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: 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
|
|
|
XR Hip Min 4 Views Rt w/ Pelvis
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 73503 RT
|
| Hospital Charge Code |
8025385
|
|
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 Hip Operative Left
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
CPT 73530 LT
|
| Hospital Charge Code |
1170239
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$171.45 |
| Max. Negotiated Rate |
$342.90 |
| Rate for Payer: Aetna of IA Commercial |
$342.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.90
|
| Rate for Payer: Aetna of IA Medicare |
$217.17
|
| Rate for Payer: Amerigroup Medicaid |
$219.76
|
| Rate for Payer: Amerigroup Medicare |
$173.16
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$171.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$217.63
|
| Rate for Payer: Medical Associates Commercial |
$285.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$171.45
|
| Rate for Payer: Midlands Choice Commercial |
$266.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$220.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$197.17
|
| Rate for Payer: United Healthcare Commercial |
$342.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$224.79
|
|
|
XR Hip Operative Left
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
CPT 73530 LT
|
| Hospital Charge Code |
1170239
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$266.70 |
| Max. Negotiated Rate |
$342.90 |
| Rate for Payer: Aetna of IA Commercial |
$342.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.90
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.75
|
| Rate for Payer: Medical Associates Commercial |
$285.75
|
| Rate for Payer: Midlands Choice Commercial |
$266.70
|
| Rate for Payer: United Healthcare Commercial |
$342.90
|
|
|
XR Hip Operative Right
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
CPT 73530 RT
|
| Hospital Charge Code |
1170241
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$266.70 |
| Max. Negotiated Rate |
$342.90 |
| Rate for Payer: Aetna of IA Commercial |
$342.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.90
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.75
|
| Rate for Payer: Medical Associates Commercial |
$285.75
|
| Rate for Payer: Midlands Choice Commercial |
$266.70
|
| Rate for Payer: United Healthcare Commercial |
$342.90
|
|
|
XR Hip Operative Right
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
CPT 73530 RT
|
| Hospital Charge Code |
1170241
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$171.45 |
| Max. Negotiated Rate |
$342.90 |
| Rate for Payer: Aetna of IA Commercial |
$342.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$342.90
|
| Rate for Payer: Aetna of IA Medicare |
$217.17
|
| Rate for Payer: Amerigroup Medicaid |
$219.76
|
| Rate for Payer: Amerigroup Medicare |
$173.16
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$285.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$171.45
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$217.63
|
| Rate for Payer: Medical Associates Commercial |
$285.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$171.45
|
| Rate for Payer: Midlands Choice Commercial |
$266.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$220.83
|
| Rate for Payer: Partners Health Alliance Commercial |
$197.17
|
| Rate for Payer: United Healthcare Commercial |
$342.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$224.79
|
|
|
XR Hips Bil w/ Pelvis 2 Views
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 73521
|
| Hospital Charge Code |
8025388
|
|
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 Hips Bil w/ Pelvis 2 Views
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 73521
|
| Hospital Charge Code |
8025388
|
|
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: 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
|
|
|
XR Hips Bil w/ Pelvis 3-4 Views
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 73522
|
| Hospital Charge Code |
8025391
|
|
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 Hips Bil w/ Pelvis 3-4 Views
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 73522
|
| Hospital Charge Code |
8025391
|
|
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: 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
|
|
|
XR Hips Bil w/ Pelvis Min 5 Views
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 73523
|
| Hospital Charge Code |
8025394
|
|
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 Hips Bil w/ Pelvis Min 5 Views
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 73523
|
| Hospital Charge Code |
8025394
|
|
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: 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
|
|
|
XR Humerus Left
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 73060 LT
|
| Hospital Charge Code |
1170245
|
|
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 Humerus Left
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 73060 LT
|
| Hospital Charge Code |
1170245
|
|
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: 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
|
|
|
XR Humerus Right
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
CPT 73060 RT
|
| Hospital Charge Code |
1170247
|
|
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: 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
|
|
|
XR Humerus Right
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
CPT 73060 RT
|
| Hospital Charge Code |
1170247
|
|
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 Hysterosalpingography
|
Facility
|
IP
|
$830.00
|
|
|
Service Code
|
CPT 74740
|
| Hospital Charge Code |
1170249
|
|
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 Hysterosalpingography
|
Facility
|
OP
|
$830.00
|
|
|
Service Code
|
CPT 74740
|
| Hospital Charge Code |
1170249
|
|
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: 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
|
|
|
XR Inj Arthrogram Shoulder LT
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
7820769
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.10 |
| Max. Negotiated Rate |
$196.20 |
| Rate for Payer: Aetna of IA Commercial |
$196.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$196.20
|
| Rate for Payer: Aetna of IA Medicare |
$124.26
|
| Rate for Payer: Amerigroup Medicaid |
$125.74
|
| Rate for Payer: Amerigroup Medicare |
$99.08
|
| Rate for Payer: Cash Price |
$174.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$163.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$98.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$124.52
|
| Rate for Payer: Medical Associates Commercial |
$163.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$98.10
|
| Rate for Payer: Midlands Choice Commercial |
$152.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$126.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.81
|
| Rate for Payer: United Healthcare Commercial |
$196.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$128.62
|
|
|
XR Inj Arthrogram Shoulder LT
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
7820769
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.60 |
| Max. Negotiated Rate |
$196.20 |
| Rate for Payer: Aetna of IA Commercial |
$196.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$196.20
|
| Rate for Payer: Cash Price |
$174.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$163.50
|
| Rate for Payer: Medical Associates Commercial |
$163.50
|
| Rate for Payer: Midlands Choice Commercial |
$152.60
|
| Rate for Payer: United Healthcare Commercial |
$196.20
|
|
|
XR Inj Arthrogram Shoulder RT
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
7820772
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.10 |
| Max. Negotiated Rate |
$196.20 |
| Rate for Payer: Aetna of IA Commercial |
$196.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$196.20
|
| Rate for Payer: Aetna of IA Medicare |
$124.26
|
| Rate for Payer: Amerigroup Medicaid |
$125.74
|
| Rate for Payer: Amerigroup Medicare |
$99.08
|
| Rate for Payer: Cash Price |
$174.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$163.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$98.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$124.52
|
| Rate for Payer: Medical Associates Commercial |
$163.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$98.10
|
| Rate for Payer: Midlands Choice Commercial |
$152.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$126.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.81
|
| Rate for Payer: United Healthcare Commercial |
$196.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$128.62
|
|
|
XR Inj Arthrogram Shoulder RT
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 23350
|
| Hospital Charge Code |
7820772
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.60 |
| Max. Negotiated Rate |
$196.20 |
| Rate for Payer: Aetna of IA Commercial |
$196.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$196.20
|
| Rate for Payer: Cash Price |
$174.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$163.50
|
| Rate for Payer: Medical Associates Commercial |
$163.50
|
| Rate for Payer: Midlands Choice Commercial |
$152.60
|
| Rate for Payer: United Healthcare Commercial |
$196.20
|
|
|
XR IVP
|
Facility
|
OP
|
$459.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
1170251
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$206.55 |
| Max. Negotiated Rate |
$413.10 |
| Rate for Payer: Aetna of IA Commercial |
$413.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$413.10
|
| Rate for Payer: Aetna of IA Medicare |
$261.63
|
| Rate for Payer: Amerigroup Medicaid |
$264.75
|
| Rate for Payer: Amerigroup Medicare |
$208.62
|
| Rate for Payer: Cash Price |
$367.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$344.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$206.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$262.18
|
| Rate for Payer: Medical Associates Commercial |
$344.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$206.55
|
| Rate for Payer: Midlands Choice Commercial |
$321.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$266.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$237.53
|
| Rate for Payer: United Healthcare Commercial |
$413.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$270.81
|
|
