Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

metroNIDAZOLE 500 mg/100 mL IV Sol [VDMC]

Facility

$58.43

Service Code	HCPCS J3490
Hospital Charge Code	10405812
Hospital Revenue Code	259
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/100 mL IV Sol [VDMC]

Facility

$58.43

Service Code	HCPCS J3490
Hospital Charge Code	10405812
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$29.64
Rate for Payer: Oscar Health of IA Commercial	$43.82
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 Tab [VDMC]

Facility

$1.26

Service Code	HCPCS A9270
Hospital Charge Code	10405741
Hospital Revenue Code	259
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 [VDMC]

Facility

$1.26

Service Code	HCPCS A9270
Hospital Charge Code	10405741
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$0.64
Rate for Payer: Oscar Health of IA Commercial	$0.95
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 [VDMC]

Facility

$14.13

Service Code	HCPCS A9270
Hospital Charge Code	13511137
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$7.17
Rate for Payer: Oscar Health of IA Commercial	$10.60
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

metroNIDAZOLE topical 1% Gel [VDMC]

Facility

$14.13

Service Code	HCPCS A9270
Hospital Charge Code	13511137
Hospital Revenue Code	259
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

MG Breast Tissue Specimen Left

Facility

$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: Molina Healthcare Managed Medicare	$76.59
Rate for Payer: Oscar Health of IA Commercial	$113.25
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

$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

$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: Molina Healthcare Managed Medicare	$76.59
Rate for Payer: Oscar Health of IA Commercial	$113.25
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

$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 Right

Facility

$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

$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: Molina Healthcare Managed Medicare	$76.59
Rate for Payer: Oscar Health of IA Commercial	$113.25
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

$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: Molina Healthcare Managed Medicare	$76.59
Rate for Payer: Oscar Health of IA Commercial	$113.25
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

$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

$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: Molina Healthcare Managed Medicare	$169.91
Rate for Payer: Oscar Health of IA Commercial	$251.25
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 Bilat.

Facility

$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 Left.

Facility

$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

$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: Molina Healthcare Managed Medicare	$149.12
Rate for Payer: Oscar Health of IA Commercial	$220.50
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

$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 Diagnostic Right.

Facility

$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: Molina Healthcare Managed Medicare	$149.12
Rate for Payer: Oscar Health of IA Commercial	$220.50
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 Screening Bilat.

Facility

$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: Molina Healthcare Managed Medicare	$153.17
Rate for Payer: Oscar Health of IA Commercial	$226.50
Rate for Payer: Partners Health Alliance Commercial	$226.50
Rate for Payer: United Healthcare Commercial	$271.80

MG Mammogram Digital Screening Bilat.

Facility

$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 Left.

Facility

$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 Left.

Facility

$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: Molina Healthcare Managed Medicare	$153.17
Rate for Payer: Oscar Health of IA Commercial	$226.50
Rate for Payer: Partners Health Alliance Commercial	$226.50
Rate for Payer: United Healthcare Commercial	$271.80

MG Mammogram Digital Screening Right.

Facility

$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: Molina Healthcare Managed Medicare	$153.17
Rate for Payer: Oscar Health of IA Commercial	$226.50
Rate for Payer: Partners Health Alliance Commercial	$226.50
Rate for Payer: United Healthcare Commercial	$271.80

Know your out-of-pocket cost for care.

All Charges