|
MG Mammogram Digital Diagnostic Right.
|
Facility
OP
|
$294.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
969803
|
|
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
|
|
|
MG Mammogram Digital Diagnostic Right.
|
Facility
IP
|
$294.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
969803
|
|
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 Screening Bilat.
|
Facility
IP
|
$302.00
|
|
|
Service Code
|
CPT 77067 50
|
| Hospital Charge Code |
969805
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$211.40 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Bilat.
|
Facility
OP
|
$302.00
|
|
|
Service Code
|
CPT 77067 50
|
| Hospital Charge Code |
969805
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$150.94 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Aetna of IA Medicare |
$172.14
|
| Rate for Payer: Amerigroup Medicaid |
$152.42
|
| Rate for Payer: Amerigroup Medicare |
$152.51
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$151.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$150.94
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$151.00
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$153.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$226.50
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Left.
|
Facility
OP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
4570784
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$150.94 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Aetna of IA Medicare |
$172.14
|
| Rate for Payer: Amerigroup Medicaid |
$152.42
|
| Rate for Payer: Amerigroup Medicare |
$152.51
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$151.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$150.94
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$151.00
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$153.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$226.50
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Left.
|
Facility
IP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
4570784
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$211.40 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Right.
|
Facility
OP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
4570787
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$150.94 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Aetna of IA Medicare |
$172.14
|
| Rate for Payer: Amerigroup Medicaid |
$152.42
|
| Rate for Payer: Amerigroup Medicare |
$152.51
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$151.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$150.94
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$151.00
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$153.26
|
| Rate for Payer: Partners Health Alliance Commercial |
$226.50
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
MG Mammogram Digital Screening Right.
|
Facility
IP
|
$302.00
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
4570787
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$211.40 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna of IA Commercial |
$271.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$271.80
|
| Rate for Payer: Cash Price |
$241.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$226.50
|
| Rate for Payer: Medical Associates Commercial |
$226.50
|
| Rate for Payer: Midlands Choice Commercial |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$271.80
|
|
|
miconazole Top 2% Crm 15gm
|
Facility
IP
|
$13.70
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700042
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Aetna of IA Commercial |
$12.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.33
|
| Rate for Payer: Cash Price |
$10.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.28
|
| Rate for Payer: Medical Associates Commercial |
$10.28
|
| Rate for Payer: Midlands Choice Commercial |
$9.59
|
| Rate for Payer: United Healthcare Commercial |
$12.33
|
|
|
miconazole Top 2% Crm 15gm
|
Facility
OP
|
$13.70
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700042
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.85 |
| Max. Negotiated Rate |
$12.33 |
| Rate for Payer: Aetna of IA Commercial |
$12.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$12.33
|
| Rate for Payer: Aetna of IA Medicare |
$7.81
|
| Rate for Payer: Amerigroup Medicaid |
$6.91
|
| Rate for Payer: Amerigroup Medicare |
$6.92
|
| Rate for Payer: Cash Price |
$10.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$10.28
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$6.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6.85
|
| Rate for Payer: Medical Associates Commercial |
$10.28
|
| Rate for Payer: Medical Associates Managed Medicare |
$6.85
|
| Rate for Payer: Midlands Choice Commercial |
$9.59
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6.95
|
| Rate for Payer: Partners Health Alliance Commercial |
$10.28
|
| Rate for Payer: United Healthcare Commercial |
$12.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$8.08
|
|
|
miconazole topical 2% Cre 45gm
|
Facility
IP
|
$22.08
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43717979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.46 |
| Max. Negotiated Rate |
$19.87 |
| Rate for Payer: Aetna of IA Commercial |
$19.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.87
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.56
|
| Rate for Payer: Medical Associates Commercial |
$16.56
|
| Rate for Payer: Midlands Choice Commercial |
$15.46
|
| Rate for Payer: United Healthcare Commercial |
$19.87
|
|
|
miconazole topical 2% Cre 45gm
|
Facility
OP
|
$22.08
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43717979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$19.87 |
| Rate for Payer: Aetna of IA Commercial |
$19.87
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$19.87
|
| Rate for Payer: Aetna of IA Medicare |
$12.59
|
| Rate for Payer: Amerigroup Medicaid |
$11.14
|
| Rate for Payer: Amerigroup Medicare |
$11.15
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$16.56
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.04
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.04
|
| Rate for Payer: Medical Associates Commercial |
$16.56
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.04
|
| Rate for Payer: Midlands Choice Commercial |
$15.46
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.21
|
| Rate for Payer: Partners Health Alliance Commercial |
$16.56
|
| Rate for Payer: United Healthcare Commercial |
$19.87
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.03
|
|
|
midazolam 1 mg/mL 2 ML SDV
|
Facility
OP
|
$41.09
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
43759811
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.54 |
| Max. Negotiated Rate |
$36.98 |
| Rate for Payer: Aetna of IA Commercial |
$36.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.98
|
| Rate for Payer: Aetna of IA Medicare |
$23.42
|
| Rate for Payer: Amerigroup Medicaid |
$20.74
|
| Rate for Payer: Amerigroup Medicare |
$20.75
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.82
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.54
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.54
|
| Rate for Payer: Medical Associates Commercial |
$30.82
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.54
|
| Rate for Payer: Midlands Choice Commercial |
$28.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.85
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.82
|
| Rate for Payer: United Healthcare Commercial |
$36.98
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.24
|
|
|
midazolam 1 mg/mL 2 ML SDV
|
Facility
IP
|
$41.09
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
43759811
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.76 |
| Max. Negotiated Rate |
$36.98 |
| Rate for Payer: Aetna of IA Commercial |
$36.98
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.98
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.82
|
| Rate for Payer: Medical Associates Commercial |
$30.82
|
| Rate for Payer: Midlands Choice Commercial |
$28.76
|
| Rate for Payer: United Healthcare Commercial |
$36.98
|
|
|
midazolam 1 mg/mL Inj 5 ML SDV
|
Facility
IP
|
$42.87
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
43748917
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.01 |
| Max. Negotiated Rate |
$38.58 |
| Rate for Payer: Aetna of IA Commercial |
$38.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.58
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.15
|
| Rate for Payer: Medical Associates Commercial |
$32.15
|
| Rate for Payer: Midlands Choice Commercial |
$30.01
|
| Rate for Payer: United Healthcare Commercial |
$38.58
|
|
|
midazolam 1 mg/mL Inj 5 ML SDV
|
Facility
OP
|
$42.87
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
43748917
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$38.58 |
| Rate for Payer: Aetna of IA Commercial |
$38.58
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$38.58
|
| Rate for Payer: Aetna of IA Medicare |
$24.44
|
| Rate for Payer: Amerigroup Medicaid |
$21.64
|
| Rate for Payer: Amerigroup Medicare |
$21.65
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.44
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.43
|
| Rate for Payer: Medical Associates Commercial |
$32.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.44
|
| Rate for Payer: Midlands Choice Commercial |
$30.01
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.15
|
| Rate for Payer: United Healthcare Commercial |
$38.58
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.29
|
|
|
midazolam 1 mg/mL MDV 5 ML vial
|
Facility
OP
|
$43.61
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
43706710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.80 |
| Max. Negotiated Rate |
$39.25 |
| Rate for Payer: Aetna of IA Commercial |
$39.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.25
|
| Rate for Payer: Aetna of IA Medicare |
$24.86
|
| Rate for Payer: Amerigroup Medicaid |
$22.01
|
| Rate for Payer: Amerigroup Medicare |
$22.02
|
| Rate for Payer: Cash Price |
$34.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.71
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$21.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$21.80
|
| Rate for Payer: Medical Associates Commercial |
$32.71
|
| Rate for Payer: Medical Associates Managed Medicare |
$21.80
|
| Rate for Payer: Midlands Choice Commercial |
$30.53
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.13
|
| Rate for Payer: Partners Health Alliance Commercial |
$32.71
|
| Rate for Payer: United Healthcare Commercial |
$39.25
|
| Rate for Payer: United Healthcare Managed Medicare |
$25.73
|
|
|
midazolam 1 mg/mL MDV 5 ML vial
|
Facility
IP
|
$43.61
|
|
|
Service Code
|
CPT J2250
|
| Hospital Charge Code |
43706710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.53 |
| Max. Negotiated Rate |
$39.25 |
| Rate for Payer: Aetna of IA Commercial |
$39.25
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.25
|
| Rate for Payer: Cash Price |
$34.89
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$32.71
|
| Rate for Payer: Medical Associates Commercial |
$32.71
|
| Rate for Payer: Midlands Choice Commercial |
$30.53
|
| Rate for Payer: United Healthcare Commercial |
$39.25
|
|
|
midazolam 2mg/mL Oral Syrup
|
Facility
OP
|
$9.67
|
|
|
Service Code
|
CPT A9270GY
|
| Hospital Charge Code |
43765018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.83 |
| Max. Negotiated Rate |
$8.70 |
| Rate for Payer: Aetna of IA Commercial |
$8.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.70
|
| Rate for Payer: Aetna of IA Medicare |
$5.51
|
| Rate for Payer: Amerigroup Medicaid |
$4.88
|
| Rate for Payer: Amerigroup Medicare |
$4.88
|
| Rate for Payer: Cash Price |
$7.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.84
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.83
|
| Rate for Payer: Medical Associates Commercial |
$7.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.84
|
| Rate for Payer: Midlands Choice Commercial |
$6.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.91
|
| Rate for Payer: Partners Health Alliance Commercial |
$7.25
|
| Rate for Payer: United Healthcare Commercial |
$8.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$5.71
|
|
|
midazolam 2mg/mL Oral Syrup
|
Facility
IP
|
$9.67
|
|
|
Service Code
|
CPT A9270GY
|
| Hospital Charge Code |
43765018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$8.70 |
| Rate for Payer: Aetna of IA Commercial |
$8.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$8.70
|
| Rate for Payer: Cash Price |
$7.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$7.25
|
| Rate for Payer: Medical Associates Commercial |
$7.25
|
| Rate for Payer: Midlands Choice Commercial |
$6.77
|
| Rate for Payer: United Healthcare Commercial |
$8.70
|
|
|
midodrine 5 mg Tab
|
Facility
IP
|
$1.59
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of IA Commercial |
$1.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.43
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.19
|
| Rate for Payer: Medical Associates Commercial |
$1.19
|
| Rate for Payer: Midlands Choice Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
|
|
midodrine 5 mg Tab
|
Facility
OP
|
$1.59
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of IA Commercial |
$1.43
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.43
|
| Rate for Payer: Aetna of IA Medicare |
$0.91
|
| Rate for Payer: Amerigroup Medicaid |
$0.80
|
| Rate for Payer: Amerigroup Medicare |
$0.80
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.19
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.79
|
| Rate for Payer: Medical Associates Commercial |
$1.19
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.80
|
| Rate for Payer: Midlands Choice Commercial |
$1.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.94
|
|
|
MILEAGE GROUND PER 10TH OF A MILE
|
Facility
OP
|
$2.00
|
|
|
Service Code
|
CPT A0425 QN
|
| Hospital Charge Code |
5966784
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of IA Commercial |
$1.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.80
|
| Rate for Payer: Aetna of IA Medicare |
$1.14
|
| Rate for Payer: Amerigroup Medicaid |
$1.01
|
| Rate for Payer: Amerigroup Medicare |
$1.01
|
| Rate for Payer: Cash Price |
$1.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.00
|
| Rate for Payer: Medical Associates Commercial |
$1.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.00
|
| Rate for Payer: Midlands Choice Commercial |
$1.40
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.50
|
| Rate for Payer: United Healthcare Commercial |
$1.80
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.70
|
|
|
MILEAGE GROUND PER 10TH OF A MILE
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
CPT A0425 QN
|
| Hospital Charge Code |
5966784
|
|
Hospital Revenue Code
|
540
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Aetna of IA Commercial |
$1.80
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.80
|
| Rate for Payer: Cash Price |
$1.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.50
|
| Rate for Payer: Medical Associates Commercial |
$1.50
|
| Rate for Payer: Midlands Choice Commercial |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.80
|
|
|
mineral oil 100% Liq 473 ml
|
Facility
IP
|
$19.42
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.59 |
| Max. Negotiated Rate |
$17.48 |
| Rate for Payer: Aetna of IA Commercial |
$17.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$17.48
|
| Rate for Payer: Cash Price |
$15.54
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$14.56
|
| Rate for Payer: Medical Associates Commercial |
$14.56
|
| Rate for Payer: Midlands Choice Commercial |
$13.59
|
| Rate for Payer: United Healthcare Commercial |
$17.48
|
|
