|
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: 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
|
|
|
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 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$298.49
|
| Rate for Payer: Wellmark IA PPO |
$328.80
|
|
|
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 + 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 + 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 w/ Air Contrast
|
Facility
|
IP
|
$454.00
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1170566
|
|
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 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$298.49
|
| Rate for Payer: Wellmark IA PPO |
$328.80
|
|
|
XR Upper GI w/ Air w/ Small Bowel
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 74249
|
| Hospital Charge Code |
1170570
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$300.60 |
| Max. Negotiated Rate |
$601.20 |
| Rate for Payer: Aetna of IA Commercial |
$601.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$601.20
|
| Rate for Payer: Aetna of IA Medicare |
$380.76
|
| Rate for Payer: Amerigroup Medicaid |
$385.30
|
| Rate for Payer: Amerigroup Medicare |
$303.61
|
| Rate for Payer: Cash Price |
$534.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$501.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$300.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$381.56
|
| Rate for Payer: Medical Associates Commercial |
$501.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$300.60
|
| Rate for Payer: Midlands Choice Commercial |
$467.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$387.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$345.69
|
| Rate for Payer: United Healthcare Commercial |
$601.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$394.12
|
|
|
XR Upper GI w/ Air w/ Small Bowel
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 74249
|
| Hospital Charge Code |
1170570
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$467.60 |
| Max. Negotiated Rate |
$601.20 |
| Rate for Payer: Aetna of IA Commercial |
$601.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$601.20
|
| Rate for Payer: Cash Price |
$534.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$501.00
|
| Rate for Payer: Medical Associates Commercial |
$501.00
|
| Rate for Payer: Midlands Choice Commercial |
$467.60
|
| Rate for Payer: United Healthcare Commercial |
$601.20
|
|
|
XR Upper GI w/ Small Bowel
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
CPT 74245
|
| Hospital Charge Code |
1170574
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$300.60 |
| Max. Negotiated Rate |
$601.20 |
| Rate for Payer: Aetna of IA Commercial |
$601.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$601.20
|
| Rate for Payer: Aetna of IA Medicare |
$380.76
|
| Rate for Payer: Amerigroup Medicaid |
$385.30
|
| Rate for Payer: Amerigroup Medicare |
$303.61
|
| Rate for Payer: Cash Price |
$534.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$501.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$300.60
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$381.56
|
| Rate for Payer: Medical Associates Commercial |
$501.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$300.60
|
| Rate for Payer: Midlands Choice Commercial |
$467.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$387.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$345.69
|
| Rate for Payer: United Healthcare Commercial |
$601.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$394.12
|
|
|
XR Upper GI w/ Small Bowel
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
CPT 74245
|
| Hospital Charge Code |
1170574
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$467.60 |
| Max. Negotiated Rate |
$601.20 |
| Rate for Payer: Aetna of IA Commercial |
$601.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$601.20
|
| Rate for Payer: Cash Price |
$534.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$501.00
|
| Rate for Payer: Medical Associates Commercial |
$501.00
|
| Rate for Payer: Midlands Choice Commercial |
$467.60
|
| Rate for Payer: United Healthcare Commercial |
$601.20
|
|
|
XR Urethrocystography Retrograde
|
Facility
|
IP
|
$830.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1170578
|
|
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 Urethrocystography Retrograde
|
Facility
|
OP
|
$830.00
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1170578
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.49 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$298.49
|
| Rate for Payer: Wellmark IA PPO |
$328.80
|
|
|
XR Urethrocystography Voiding
|
Facility
|
OP
|
$830.00
|
|
|
Service Code
|
CPT 74455
|
| Hospital Charge Code |
1170580
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.49 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$298.49
|
| Rate for Payer: Wellmark IA PPO |
$328.80
|
|
|
XR Urethrocystography Voiding
|
Facility
|
IP
|
$830.00
|
|
|
Service Code
|
CPT 74455
|
| Hospital Charge Code |
1170580
|
|
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 Venogram Lower Extremity Left
|
Facility
|
OP
|
$830.00
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
1170592
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$373.50 |
| Max. Negotiated Rate |
$1,136.36 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,031.60
|
| Rate for Payer: Wellmark IA PPO |
$1,136.36
|
|
|
XR Venogram Lower Extremity Left
|
Facility
|
IP
|
$830.00
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
1170592
|
|
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 Venogram Lower Extremity Right
|
Facility
|
OP
|
$830.00
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
1170594
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$373.50 |
| Max. Negotiated Rate |
$1,136.36 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,031.60
|
| Rate for Payer: Wellmark IA PPO |
$1,136.36
|
|
|
XR Venogram Lower Extremity Right
|
Facility
|
IP
|
$830.00
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
1170594
|
|
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 Venogram Upper Extremity Left
|
Facility
|
OP
|
$830.00
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
1170598
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$373.50 |
| Max. Negotiated Rate |
$1,136.36 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,031.60
|
| Rate for Payer: Wellmark IA PPO |
$1,136.36
|
|
|
XR Venogram Upper Extremity Left
|
Facility
|
IP
|
$830.00
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
1170598
|
|
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 Venogram Upper Extremity Right
|
Facility
|
IP
|
$830.00
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
1170600
|
|
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 Venogram Upper Extremity Right
|
Facility
|
OP
|
$830.00
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
1170600
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$373.50 |
| Max. Negotiated Rate |
$1,136.36 |
| 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: 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
|
| Rate for Payer: Wellmark IA HMO WHPI |
$1,031.60
|
| Rate for Payer: Wellmark IA PPO |
$1,136.36
|
|
|
XR Wrist 2 Views Left
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
CPT 73100 LT
|
| Hospital Charge Code |
1170606
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$88.90 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of IA Commercial |
$114.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$114.30
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$95.25
|
| Rate for Payer: Medical Associates Commercial |
$95.25
|
| Rate for Payer: Midlands Choice Commercial |
$88.90
|
| Rate for Payer: United Healthcare Commercial |
$114.30
|
|
