|
XR Toes 3rd Digit Left
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T2|LT
|
| Hospital Charge Code |
1170524
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
XR Toes 3rd Digit Left
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T2|LT
|
| Hospital Charge Code |
1170524
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 3rd Digit Right
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T7|RT
|
| Hospital Charge Code |
1170526
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 3rd Digit Right
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T7|RT
|
| Hospital Charge Code |
1170526
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
XR Toes 4th Digit Left
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T3|LT
|
| Hospital Charge Code |
1170528
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
XR Toes 4th Digit Left
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T3|LT
|
| Hospital Charge Code |
1170528
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 4th Digit Right
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T8|RT
|
| Hospital Charge Code |
1170530
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
XR Toes 4th Digit Right
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T8|RT
|
| Hospital Charge Code |
1170530
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 5th Digit Left
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T4|LT
|
| Hospital Charge Code |
1170532
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
XR Toes 5th Digit Left
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T4|LT
|
| Hospital Charge Code |
1170532
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 5th Digit Right
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T9|RT
|
| Hospital Charge Code |
1170534
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
XR Toes 5th Digit Right
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T9|RT
|
| Hospital Charge Code |
1170534
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes Great Left
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 TA|LT
|
| Hospital Charge Code |
1170536
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes Great Left
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 TA|LT
|
| Hospital Charge Code |
1170536
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
XR Toes Great Right
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T5|RT
|
| Hospital Charge Code |
1170538
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
|
|
XR Toes Great Right
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T5|RT
|
| Hospital Charge Code |
1170538
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of IA Commercial |
$107.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$107.10
|
| Rate for Payer: Aetna of IA Medicare |
$67.83
|
| Rate for Payer: Amerigroup Medicaid |
$68.64
|
| Rate for Payer: Amerigroup Medicare |
$54.09
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$89.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$53.55
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.97
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$53.55
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$68.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$61.58
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Upper Extremity Infant Left
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 73092 LT
|
| Hospital Charge Code |
1170558
|
|
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 Upper Extremity Infant Left
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 73092 LT
|
| Hospital Charge Code |
1170558
|
|
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 Upper Extremity Infant Right
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
CPT 73092 RT
|
| Hospital Charge Code |
1170560
|
|
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 Upper Extremity Infant Right
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
CPT 73092 RT
|
| Hospital Charge Code |
1170560
|
|
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 Upper GI
|
Facility
|
IP
|
$454.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1170562
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$317.80 |
| Max. Negotiated Rate |
$408.60 |
| Rate for Payer: Aetna of IA Commercial |
$408.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$408.60
|
| Rate for Payer: Cash Price |
$363.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$340.50
|
| Rate for Payer: Medical Associates Commercial |
$340.50
|
| Rate for Payer: Midlands Choice Commercial |
$317.80
|
| Rate for Payer: United Healthcare Commercial |
$408.60
|
|
|
XR Upper GI
|
Facility
|
OP
|
$454.00
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1170562
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$204.30 |
| Max. Negotiated Rate |
$408.60 |
| Rate for Payer: Aetna of IA Commercial |
$408.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$408.60
|
| Rate for Payer: Aetna of IA Medicare |
$258.78
|
| Rate for Payer: Amerigroup Medicaid |
$261.87
|
| Rate for Payer: Amerigroup Medicare |
$206.34
|
| Rate for Payer: Cash Price |
$363.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$340.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$204.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$259.32
|
| Rate for Payer: Medical Associates Commercial |
$340.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$204.30
|
| Rate for Payer: Midlands Choice Commercial |
$317.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$263.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$234.94
|
| Rate for Payer: United Healthcare Commercial |
$408.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$267.86
|
|
|
XR Upper GI + KUB
|
Facility
|
OP
|
$486.00
|
|
|
Service Code
|
CPT 74241
|
| Hospital Charge Code |
1170564
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$218.70 |
| Max. Negotiated Rate |
$437.40 |
| Rate for Payer: Aetna of IA Commercial |
$437.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$437.40
|
| Rate for Payer: Aetna of IA Medicare |
$277.02
|
| Rate for Payer: Amerigroup Medicaid |
$280.32
|
| Rate for Payer: Amerigroup Medicare |
$220.89
|
| Rate for Payer: Cash Price |
$388.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$364.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$218.70
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$277.60
|
| Rate for Payer: Medical Associates Commercial |
$364.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$218.70
|
| Rate for Payer: Midlands Choice Commercial |
$340.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$281.69
|
| Rate for Payer: Partners Health Alliance Commercial |
$251.50
|
| Rate for Payer: United Healthcare Commercial |
$437.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$286.74
|
|
|
XR Upper GI + KUB
|
Facility
|
IP
|
$486.00
|
|
|
Service Code
|
CPT 74241
|
| Hospital Charge Code |
1170564
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$340.20 |
| Max. Negotiated Rate |
$437.40 |
| Rate for Payer: Aetna of IA Commercial |
$437.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$437.40
|
| Rate for Payer: Cash Price |
$388.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$364.50
|
| Rate for Payer: Medical Associates Commercial |
$364.50
|
| Rate for Payer: Midlands Choice Commercial |
$340.20
|
| Rate for Payer: United Healthcare Commercial |
$437.40
|
|
|
XR Upper GI w/ Air Contrast
|
Facility
|
OP
|
$454.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1170566
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$204.30 |
| Max. Negotiated Rate |
$408.60 |
| Rate for Payer: Aetna of IA Commercial |
$408.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$408.60
|
| Rate for Payer: Aetna of IA Medicare |
$258.78
|
| Rate for Payer: Amerigroup Medicaid |
$261.87
|
| Rate for Payer: Amerigroup Medicare |
$206.34
|
| Rate for Payer: Cash Price |
$363.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$340.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$204.30
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$259.32
|
| Rate for Payer: Medical Associates Commercial |
$340.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$204.30
|
| Rate for Payer: Midlands Choice Commercial |
$317.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$263.14
|
| Rate for Payer: Partners Health Alliance Commercial |
$234.94
|
| Rate for Payer: United Healthcare Commercial |
$408.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$267.86
|
|
