|
XR Tibia/Fibula Right
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 73590 RT
|
| Hospital Charge Code |
1170518
|
|
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 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 |
$81.00 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna of IA Commercial |
$162.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$162.00
|
| Rate for Payer: Aetna of IA Medicare |
$102.60
|
| Rate for Payer: Amerigroup Medicaid |
$103.82
|
| Rate for Payer: Amerigroup Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$135.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$81.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$102.82
|
| Rate for Payer: Medical Associates Commercial |
$135.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$81.00
|
| Rate for Payer: Midlands Choice Commercial |
$126.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$104.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$93.15
|
| Rate for Payer: United Healthcare Commercial |
$162.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$106.20
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Toes 2nd Digit Left
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T1|LT
|
| Hospital Charge Code |
1170520
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Toes 2nd Digit Left
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T1|LT
|
| 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
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T6|RT
|
| Hospital Charge Code |
1170522
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
XR Toes 2nd Digit Right
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 73660 T6|RT
|
| 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 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 |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 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 |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 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 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 |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 |
$114.03 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
|
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 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$103.51
|
| Rate for Payer: Wellmark IA PPO |
$114.03
|
|
