|
metoprolol SUC XL 24 HR 25 mg ER Tab
|
Facility
OP
|
$1.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Aetna of IA Medicare |
$0.71
|
| Rate for Payer: Amerigroup Medicaid |
$0.63
|
| Rate for Payer: Amerigroup Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.62
|
| Rate for Payer: Medical Associates Commercial |
$0.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.63
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
|
metoprolol SUC XL 24 HR 50 mg ER Tab
|
Facility
IP
|
$1.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.94
|
| Rate for Payer: Medical Associates Commercial |
$0.94
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
|
|
metoprolol SUC XL 24 HR 50 mg ER Tab
|
Facility
OP
|
$1.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Aetna of IA Medicare |
$0.71
|
| Rate for Payer: Amerigroup Medicaid |
$0.63
|
| Rate for Payer: Amerigroup Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.62
|
| Rate for Payer: Medical Associates Commercial |
$0.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.63
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
|
metoprolol TARTRATE 25 mg tab
|
Facility
OP
|
$1.18
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43721044
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of IA Commercial |
$1.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.06
|
| Rate for Payer: Aetna of IA Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicaid |
$0.60
|
| Rate for Payer: Amerigroup Medicare |
$0.60
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.89
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.59
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.59
|
| Rate for Payer: Medical Associates Commercial |
$0.89
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.59
|
| Rate for Payer: Midlands Choice Commercial |
$0.83
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.89
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.70
|
|
|
metoprolol TARTRATE 25 mg tab
|
Facility
IP
|
$1.18
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43721044
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of IA Commercial |
$1.06
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.06
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.89
|
| Rate for Payer: Medical Associates Commercial |
$0.89
|
| Rate for Payer: Midlands Choice Commercial |
$0.83
|
| Rate for Payer: United Healthcare Commercial |
$1.06
|
|
|
metoprolol TARTRATE 50 mg Tab
|
Facility
IP
|
$1.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.94
|
| Rate for Payer: Medical Associates Commercial |
$0.94
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
|
|
metoprolol TARTRATE 50 mg Tab
|
Facility
OP
|
$1.25
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of IA Commercial |
$1.12
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.12
|
| Rate for Payer: Aetna of IA Medicare |
$0.71
|
| Rate for Payer: Amerigroup Medicaid |
$0.63
|
| Rate for Payer: Amerigroup Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.94
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.62
|
| Rate for Payer: Medical Associates Commercial |
$0.94
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.63
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
|
metroNIDAZOLE 500 mg/100 mL IV Sol
|
Facility
OP
|
$58.43
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701678
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.20 |
| Max. Negotiated Rate |
$52.59 |
| Rate for Payer: Aetna of IA Commercial |
$52.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.59
|
| Rate for Payer: Aetna of IA Medicare |
$33.31
|
| Rate for Payer: Amerigroup Medicaid |
$29.49
|
| Rate for Payer: Amerigroup Medicare |
$29.51
|
| Rate for Payer: Cash Price |
$46.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.82
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$29.22
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$29.20
|
| Rate for Payer: Medical Associates Commercial |
$43.82
|
| Rate for Payer: Medical Associates Managed Medicare |
$29.22
|
| Rate for Payer: Midlands Choice Commercial |
$40.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$29.65
|
| Rate for Payer: Partners Health Alliance Commercial |
$43.82
|
| Rate for Payer: United Healthcare Commercial |
$52.59
|
| Rate for Payer: United Healthcare Managed Medicare |
$34.47
|
|
|
metroNIDAZOLE 500 mg/100 mL IV Sol
|
Facility
IP
|
$58.43
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43701678
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.90 |
| Max. Negotiated Rate |
$52.59 |
| Rate for Payer: Aetna of IA Commercial |
$52.59
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$52.59
|
| Rate for Payer: Cash Price |
$46.75
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$43.82
|
| Rate for Payer: Medical Associates Commercial |
$43.82
|
| Rate for Payer: Midlands Choice Commercial |
$40.90
|
| Rate for Payer: United Healthcare Commercial |
$52.59
|
|
|
metroNIDAZOLE 500 mg Tab
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
|
|
metroNIDAZOLE 500 mg Tab
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43706218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of IA Commercial |
$1.13
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.13
|
| Rate for Payer: Aetna of IA Medicare |
$0.72
|
| Rate for Payer: Amerigroup Medicaid |
$0.64
|
| Rate for Payer: Amerigroup Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.95
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.63
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.63
|
| Rate for Payer: Medical Associates Commercial |
$0.95
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.63
|
| Rate for Payer: Midlands Choice Commercial |
$0.88
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.64
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.13
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.74
|
|
|
metroNIDAZOLE topical 1% Gel
|
Facility
IP
|
$14.13
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$12.72 |
| Rate for Payer: Aetna of IA Commercial |
$12.72
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.72
|
| Rate for Payer: Cash Price |
$11.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.60
|
| Rate for Payer: Medical Associates Commercial |
$10.60
|
| Rate for Payer: Midlands Choice Commercial |
$9.89
|
| Rate for Payer: United Healthcare Commercial |
$12.72
|
|
|
metroNIDAZOLE topical 1% Gel
|
Facility
OP
|
$14.13
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43702010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$12.72 |
| Rate for Payer: Aetna of IA Commercial |
$12.72
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.72
|
| Rate for Payer: Aetna of IA Medicare |
$8.05
|
| Rate for Payer: Amerigroup Medicaid |
$7.13
|
| Rate for Payer: Amerigroup Medicare |
$7.14
|
| Rate for Payer: Cash Price |
$11.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.60
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$7.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7.06
|
| Rate for Payer: Medical Associates Commercial |
$10.60
|
| Rate for Payer: Medical Associates Managed Medicare |
$7.06
|
| Rate for Payer: Midlands Choice Commercial |
$9.89
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$7.17
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.60
|
| Rate for Payer: United Healthcare Commercial |
$12.72
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.34
|
|
|
MG Breast Tissue Specimen Left
|
Facility
IP
|
$151.00
|
|
|
Service Code
|
CPT 76098 LT
|
| Hospital Charge Code |
6800837
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
|
|
MG Breast Tissue Specimen Left
|
Facility
OP
|
$151.00
|
|
|
Service Code
|
CPT 76098 LT
|
| Hospital Charge Code |
6800837
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.47 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Aetna of IA Medicare |
$86.07
|
| Rate for Payer: Amerigroup Medicaid |
$76.21
|
| Rate for Payer: Amerigroup Medicare |
$76.26
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$75.47
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$113.25
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$89.09
|
|
|
MG Breast Tissue Specimen Left.
|
Facility
IP
|
$151.00
|
|
|
Service Code
|
CPT 76098 LT
|
| Hospital Charge Code |
969777
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
|
|
MG Breast Tissue Specimen Left.
|
Facility
OP
|
$151.00
|
|
|
Service Code
|
CPT 76098 LT
|
| Hospital Charge Code |
969777
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.47 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Aetna of IA Medicare |
$86.07
|
| Rate for Payer: Amerigroup Medicaid |
$76.21
|
| Rate for Payer: Amerigroup Medicare |
$76.26
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$75.47
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$113.25
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$89.09
|
|
|
MG Breast Tissue Specimen Right
|
Facility
IP
|
$151.00
|
|
|
Service Code
|
CPT 76098 RT
|
| Hospital Charge Code |
6800840
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
|
|
MG Breast Tissue Specimen Right
|
Facility
OP
|
$151.00
|
|
|
Service Code
|
CPT 76098 RT
|
| Hospital Charge Code |
6800840
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.47 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Aetna of IA Medicare |
$86.07
|
| Rate for Payer: Amerigroup Medicaid |
$76.21
|
| Rate for Payer: Amerigroup Medicare |
$76.26
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$75.47
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$113.25
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$89.09
|
|
|
MG Breast Tissue Specimen Right.
|
Facility
OP
|
$151.00
|
|
|
Service Code
|
CPT 76098 RT
|
| Hospital Charge Code |
969780
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.47 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Aetna of IA Medicare |
$86.07
|
| Rate for Payer: Amerigroup Medicaid |
$76.21
|
| Rate for Payer: Amerigroup Medicare |
$76.26
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$75.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$75.47
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$75.50
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$76.63
|
| Rate for Payer: Partners Health Alliance Commercial |
$113.25
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$89.09
|
|
|
MG Breast Tissue Specimen Right.
|
Facility
IP
|
$151.00
|
|
|
Service Code
|
CPT 76098 RT
|
| Hospital Charge Code |
969780
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.70 |
| Max. Negotiated Rate |
$135.90 |
| Rate for Payer: Aetna of IA Commercial |
$135.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$135.90
|
| Rate for Payer: Cash Price |
$120.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$113.25
|
| Rate for Payer: Medical Associates Commercial |
$113.25
|
| Rate for Payer: Midlands Choice Commercial |
$105.70
|
| Rate for Payer: United Healthcare Commercial |
$135.90
|
|
|
MG Mammogram Digital Diagnostic Bilat.
|
Facility
IP
|
$335.00
|
|
|
Service Code
|
CPT 77066 50
|
| Hospital Charge Code |
969799
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$234.50 |
| Max. Negotiated Rate |
$301.50 |
| Rate for Payer: Aetna of IA Commercial |
$301.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$301.50
|
| Rate for Payer: Cash Price |
$268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$251.25
|
| Rate for Payer: Medical Associates Commercial |
$251.25
|
| Rate for Payer: Midlands Choice Commercial |
$234.50
|
| Rate for Payer: United Healthcare Commercial |
$301.50
|
|
|
MG Mammogram Digital Diagnostic Bilat.
|
Facility
OP
|
$335.00
|
|
|
Service Code
|
CPT 77066 50
|
| Hospital Charge Code |
969799
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$167.43 |
| Max. Negotiated Rate |
$301.50 |
| Rate for Payer: Aetna of IA Commercial |
$301.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$301.50
|
| Rate for Payer: Aetna of IA Medicare |
$190.95
|
| Rate for Payer: Amerigroup Medicaid |
$169.07
|
| Rate for Payer: Amerigroup Medicare |
$169.18
|
| Rate for Payer: Cash Price |
$268.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$251.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$167.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$167.43
|
| Rate for Payer: Medical Associates Commercial |
$251.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$167.50
|
| Rate for Payer: Midlands Choice Commercial |
$234.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$170.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$251.25
|
| Rate for Payer: United Healthcare Commercial |
$301.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$197.65
|
|
|
MG Mammogram Digital Diagnostic Left.
|
Facility
IP
|
$294.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
969801
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$205.80 |
| Max. Negotiated Rate |
$264.60 |
| Rate for Payer: Aetna of IA Commercial |
$264.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$264.60
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$220.50
|
| Rate for Payer: Medical Associates Commercial |
$220.50
|
| Rate for Payer: Midlands Choice Commercial |
$205.80
|
| Rate for Payer: United Healthcare Commercial |
$264.60
|
|
|
MG Mammogram Digital Diagnostic Left.
|
Facility
OP
|
$294.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
969801
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$146.94 |
| Max. Negotiated Rate |
$264.60 |
| Rate for Payer: Aetna of IA Commercial |
$264.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$264.60
|
| Rate for Payer: Aetna of IA Medicare |
$167.58
|
| Rate for Payer: Amerigroup Medicaid |
$148.38
|
| Rate for Payer: Amerigroup Medicare |
$148.47
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$220.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$147.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$146.94
|
| Rate for Payer: Medical Associates Commercial |
$220.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$147.00
|
| Rate for Payer: Midlands Choice Commercial |
$205.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$149.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$220.50
|
| Rate for Payer: United Healthcare Commercial |
$264.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$173.46
|
|
