|
XR Tibia/Fibula Right
|
Facility
OP
|
$146.00
|
|
|
Service Code
|
CPT 73590 RT
|
| Hospital Charge Code |
1170518
|
|
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 TMJ Open and Closed Bilateral
|
Facility
IP
|
$180.00
|
|
|
Service Code
|
CPT 70330 50
|
| Hospital Charge Code |
1170502
|
|
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 TMJ Open and Closed Bilateral
|
Facility
OP
|
$180.00
|
|
|
Service Code
|
CPT 70330 50
|
| Hospital Charge Code |
1170502
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.96 |
| 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 |
$90.85
|
| Rate for Payer: Amerigroup Medicare |
$90.90
|
| 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 |
$90.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.96
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$90.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$91.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$135.00
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
|
|
XR Toes 2nd Digit Left
|
Facility
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T1
|
| Hospital Charge Code |
1170520
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 2nd Digit Left
|
Facility
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T1
|
| Hospital Charge Code |
1170520
|
|
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 2nd Digit Right
|
Facility
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T6
|
| Hospital Charge Code |
1170522
|
|
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 2nd Digit Right
|
Facility
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T6
|
| Hospital Charge Code |
1170522
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 3rd Digit Left
|
Facility
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T2
|
| Hospital Charge Code |
1170524
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 3rd Digit Left
|
Facility
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T2
|
| 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 Right
|
Facility
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T7
|
| Hospital Charge Code |
1170526
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| 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
|
| 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
|
| 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
|
| Hospital Charge Code |
1170528
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes 4th Digit Right
|
Facility
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T8
|
| Hospital Charge Code |
1170530
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| 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
|
| 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 5th Digit Left
|
Facility
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T4
|
| 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
|
| Hospital Charge Code |
1170532
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| 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
|
| 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
|
| Hospital Charge Code |
1170534
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| 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
|
| 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 Left
|
Facility
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 TA
|
| Hospital Charge Code |
1170536
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$107.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$70.21
|
|
|
XR Toes Great Right
|
Facility
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T5
|
| 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
|
| Hospital Charge Code |
1170538
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.48 |
| 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 |
$60.06
|
| Rate for Payer: Amerigroup Medicare |
$60.10
|
| 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 |
$59.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$59.48
|
| Rate for Payer: Medical Associates Commercial |
$89.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$59.50
|
| Rate for Payer: Midlands Choice Commercial |
$83.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$60.39
|
| Rate for Payer: Partners Health Alliance Commercial |
$89.25
|
| 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 |
$87.96 |
| 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 |
$88.83
|
| Rate for Payer: Amerigroup Medicare |
$88.88
|
| 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 |
$88.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$87.96
|
| Rate for Payer: Medical Associates Commercial |
$132.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$88.00
|
| Rate for Payer: Midlands Choice Commercial |
$123.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$89.32
|
| Rate for Payer: Partners Health Alliance Commercial |
$132.00
|
| Rate for Payer: United Healthcare Commercial |
$158.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$103.84
|
|
