|
glucagon recombinant 1 mg Syringe kit
|
Facility
OP
|
$803.12
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
43700194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$401.40 |
| Max. Negotiated Rate |
$722.81 |
| Rate for Payer: Aetna of IA Commercial |
$722.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$722.81
|
| Rate for Payer: Aetna of IA Medicare |
$457.78
|
| Rate for Payer: Amerigroup Medicaid |
$405.33
|
| Rate for Payer: Amerigroup Medicare |
$405.58
|
| Rate for Payer: Cash Price |
$642.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$602.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$401.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$401.40
|
| Rate for Payer: Medical Associates Commercial |
$602.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$401.56
|
| Rate for Payer: Midlands Choice Commercial |
$562.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$407.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$602.34
|
| Rate for Payer: United Healthcare Commercial |
$722.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$473.84
|
|
|
glucagon recombinant 1 mg Syringe kit
|
Facility
IP
|
$803.12
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
43700194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$562.18 |
| Max. Negotiated Rate |
$722.81 |
| Rate for Payer: Aetna of IA Commercial |
$722.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$722.81
|
| Rate for Payer: Cash Price |
$642.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$602.34
|
| Rate for Payer: Medical Associates Commercial |
$602.34
|
| Rate for Payer: Midlands Choice Commercial |
$562.18
|
| Rate for Payer: United Healthcare Commercial |
$722.81
|
|
|
glucagon recombinant 1 mg Vial
|
Facility
OP
|
$835.52
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
43701000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$417.59 |
| Max. Negotiated Rate |
$751.97 |
| Rate for Payer: Aetna of IA Commercial |
$751.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$751.97
|
| Rate for Payer: Aetna of IA Medicare |
$476.25
|
| Rate for Payer: Amerigroup Medicaid |
$421.69
|
| Rate for Payer: Amerigroup Medicare |
$421.94
|
| Rate for Payer: Cash Price |
$668.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$626.64
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$417.76
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$417.59
|
| Rate for Payer: Medical Associates Commercial |
$626.64
|
| Rate for Payer: Medical Associates Managed Medicare |
$417.76
|
| Rate for Payer: Midlands Choice Commercial |
$584.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$424.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$626.64
|
| Rate for Payer: United Healthcare Commercial |
$751.97
|
| Rate for Payer: United Healthcare Managed Medicare |
$492.96
|
|
|
glucagon recombinant 1 mg Vial
|
Facility
IP
|
$835.52
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
43701000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$584.86 |
| Max. Negotiated Rate |
$751.97 |
| Rate for Payer: Aetna of IA Commercial |
$751.97
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$751.97
|
| Rate for Payer: Cash Price |
$668.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$626.64
|
| Rate for Payer: Medical Associates Commercial |
$626.64
|
| Rate for Payer: Midlands Choice Commercial |
$584.86
|
| Rate for Payer: United Healthcare Commercial |
$751.97
|
|
|
GLUCOSE
|
Facility
OP
|
$41.00
|
|
|
Service Code
|
CPT 82947
|
| Hospital Charge Code |
633593
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna of IA Commercial |
$36.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.90
|
| Rate for Payer: Aetna of IA Medicare |
$23.37
|
| Rate for Payer: Amerigroup Medicaid |
$20.69
|
| Rate for Payer: Amerigroup Medicare |
$20.70
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.49
|
| Rate for Payer: Medical Associates Commercial |
$30.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.50
|
| Rate for Payer: Midlands Choice Commercial |
$28.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.75
|
| Rate for Payer: United Healthcare Commercial |
$36.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.19
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
GLUCOSE
|
Facility
IP
|
$41.00
|
|
|
Service Code
|
CPT 82947
|
| Hospital Charge Code |
4016418
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna of IA Commercial |
$36.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.90
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.75
|
| Rate for Payer: Medical Associates Commercial |
$30.75
|
| Rate for Payer: Midlands Choice Commercial |
$28.70
|
| Rate for Payer: United Healthcare Commercial |
$36.90
|
|
|
GLUCOSE
|
Facility
IP
|
$41.00
|
|
|
Service Code
|
CPT 82947
|
| Hospital Charge Code |
633593
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$28.70 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna of IA Commercial |
$36.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.90
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.75
|
| Rate for Payer: Medical Associates Commercial |
$30.75
|
| Rate for Payer: Midlands Choice Commercial |
$28.70
|
| Rate for Payer: United Healthcare Commercial |
$36.90
|
|
|
GLUCOSE
|
Facility
OP
|
$41.00
|
|
|
Service Code
|
CPT 82947
|
| Hospital Charge Code |
4016418
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna of IA Commercial |
$36.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$36.90
|
| Rate for Payer: Aetna of IA Medicare |
$23.37
|
| Rate for Payer: Amerigroup Medicaid |
$20.69
|
| Rate for Payer: Amerigroup Medicare |
$20.70
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$30.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.49
|
| Rate for Payer: Medical Associates Commercial |
$30.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.50
|
| Rate for Payer: Midlands Choice Commercial |
$28.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$20.81
|
| Rate for Payer: Partners Health Alliance Commercial |
$30.75
|
| Rate for Payer: United Healthcare Commercial |
$36.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.19
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
GLUCOSE POST DOSE
|
Facility
IP
|
$45.00
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
633597
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna of IA Commercial |
$40.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$40.50
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.75
|
| Rate for Payer: Medical Associates Commercial |
$33.75
|
| Rate for Payer: Midlands Choice Commercial |
$31.50
|
| Rate for Payer: United Healthcare Commercial |
$40.50
|
|
|
GLUCOSE POST DOSE
|
Facility
OP
|
$45.00
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
633597
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna of IA Commercial |
$40.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$40.50
|
| Rate for Payer: Aetna of IA Medicare |
$25.65
|
| Rate for Payer: Amerigroup Medicaid |
$22.71
|
| Rate for Payer: Amerigroup Medicare |
$22.72
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.49
|
| Rate for Payer: Medical Associates Commercial |
$33.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.50
|
| Rate for Payer: Midlands Choice Commercial |
$31.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.84
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.75
|
| Rate for Payer: United Healthcare Commercial |
$40.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$26.55
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
Glutamic Acid Decarboxylase Ab DMCL
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
8694176
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
Glutamic Acid Decarboxylase Ab DMCL
|
Facility
OP
|
$114.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
8694176
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$57.54
|
| Rate for Payer: Amerigroup Medicare |
$57.57
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.98
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.00
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
glyBURIDE 5 mg Tab
|
Facility
IP
|
$1.15
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701344
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of IA Commercial |
$1.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.04
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.86
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Midlands Choice Commercial |
$0.81
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
|
|
glyBURIDE 5 mg Tab
|
Facility
OP
|
$1.15
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701344
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna of IA Commercial |
$1.04
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.04
|
| Rate for Payer: Aetna of IA Medicare |
$0.66
|
| Rate for Payer: Amerigroup Medicaid |
$0.58
|
| Rate for Payer: Amerigroup Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$0.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.57
|
| Rate for Payer: Medical Associates Commercial |
$0.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.58
|
| Rate for Payer: Midlands Choice Commercial |
$0.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.68
|
|
|
glyBURIDE micronized 3 mg Tab
|
Facility
OP
|
$1.85
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of IA Commercial |
$1.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.66
|
| Rate for Payer: Aetna of IA Medicare |
$1.05
|
| Rate for Payer: Amerigroup Medicaid |
$0.93
|
| Rate for Payer: Amerigroup Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.39
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.92
|
| Rate for Payer: Medical Associates Commercial |
$1.39
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.93
|
| Rate for Payer: Midlands Choice Commercial |
$1.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.94
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.39
|
| Rate for Payer: United Healthcare Commercial |
$1.66
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.09
|
|
|
glyBURIDE micronized 3 mg Tab
|
Facility
IP
|
$1.85
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701172
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of IA Commercial |
$1.66
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.66
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.39
|
| Rate for Payer: Medical Associates Commercial |
$1.39
|
| Rate for Payer: Midlands Choice Commercial |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.66
|
|
|
glycerin
|
Facility
IP
|
$5.66
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: Aetna of IA Commercial |
$5.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.09
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.24
|
| Rate for Payer: Medical Associates Commercial |
$4.24
|
| Rate for Payer: Midlands Choice Commercial |
$3.96
|
| Rate for Payer: United Healthcare Commercial |
$5.09
|
|
|
glycerin
|
Facility
OP
|
$5.66
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43701890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$5.09 |
| Rate for Payer: Aetna of IA Commercial |
$5.09
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$5.09
|
| Rate for Payer: Aetna of IA Medicare |
$3.23
|
| Rate for Payer: Amerigroup Medicaid |
$2.86
|
| Rate for Payer: Amerigroup Medicare |
$2.86
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$4.24
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.83
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.83
|
| Rate for Payer: Medical Associates Commercial |
$4.24
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.83
|
| Rate for Payer: Midlands Choice Commercial |
$3.96
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.87
|
| Rate for Payer: Partners Health Alliance Commercial |
$4.24
|
| Rate for Payer: United Healthcare Commercial |
$5.09
|
| Rate for Payer: United Healthcare Managed Medicare |
$3.34
|
|
|
glycerin pediatric Supp Jar
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of IA Commercial |
$7.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.20
|
| Rate for Payer: Aetna of IA Medicare |
$4.56
|
| Rate for Payer: Amerigroup Medicaid |
$4.04
|
| Rate for Payer: Amerigroup Medicare |
$4.04
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$4.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$4.00
|
| Rate for Payer: Medical Associates Commercial |
$6.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$4.00
|
| Rate for Payer: Midlands Choice Commercial |
$5.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$4.06
|
| Rate for Payer: Partners Health Alliance Commercial |
$6.00
|
| Rate for Payer: United Healthcare Commercial |
$7.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$4.72
|
|
|
glycerin pediatric Supp Jar
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43700247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of IA Commercial |
$7.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$7.20
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$6.00
|
| Rate for Payer: Medical Associates Commercial |
$6.00
|
| Rate for Payer: Midlands Choice Commercial |
$5.60
|
| Rate for Payer: United Healthcare Commercial |
$7.20
|
|
|
glycopyrrolate 0.2 mg/mL 2ml SDV Sol
|
Facility
OP
|
$24.20
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.10 |
| Max. Negotiated Rate |
$21.78 |
| Rate for Payer: Aetna of IA Commercial |
$21.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.78
|
| Rate for Payer: Aetna of IA Medicare |
$13.79
|
| Rate for Payer: Amerigroup Medicaid |
$12.21
|
| Rate for Payer: Amerigroup Medicare |
$12.22
|
| Rate for Payer: Cash Price |
$19.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.15
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$12.10
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12.10
|
| Rate for Payer: Medical Associates Commercial |
$18.15
|
| Rate for Payer: Medical Associates Managed Medicare |
$12.10
|
| Rate for Payer: Midlands Choice Commercial |
$16.94
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12.28
|
| Rate for Payer: Partners Health Alliance Commercial |
$18.15
|
| Rate for Payer: United Healthcare Commercial |
$21.78
|
| Rate for Payer: United Healthcare Managed Medicare |
$14.28
|
|
|
glycopyrrolate 0.2 mg/mL 2ml SDV Sol
|
Facility
IP
|
$24.20
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43702180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.94 |
| Max. Negotiated Rate |
$21.78 |
| Rate for Payer: Aetna of IA Commercial |
$21.78
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$21.78
|
| Rate for Payer: Cash Price |
$19.36
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$18.15
|
| Rate for Payer: Medical Associates Commercial |
$18.15
|
| Rate for Payer: Midlands Choice Commercial |
$16.94
|
| Rate for Payer: United Healthcare Commercial |
$21.78
|
|
|
glycopyrrolate 1 mg Tab
|
Facility
IP
|
$4.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43721385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Aetna of IA Commercial |
$3.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.75
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.13
|
| Rate for Payer: Medical Associates Commercial |
$3.13
|
| Rate for Payer: Midlands Choice Commercial |
$2.92
|
| Rate for Payer: United Healthcare Commercial |
$3.75
|
|
|
glycopyrrolate 1 mg Tab
|
Facility
OP
|
$4.17
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43721385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Aetna of IA Commercial |
$3.75
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.75
|
| Rate for Payer: Aetna of IA Medicare |
$2.38
|
| Rate for Payer: Amerigroup Medicaid |
$2.10
|
| Rate for Payer: Amerigroup Medicare |
$2.11
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$3.13
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$2.08
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$2.08
|
| Rate for Payer: Medical Associates Commercial |
$3.13
|
| Rate for Payer: Medical Associates Managed Medicare |
$2.08
|
| Rate for Payer: Midlands Choice Commercial |
$2.92
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$3.13
|
| Rate for Payer: United Healthcare Commercial |
$3.75
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.46
|
|
|
GRAFT CHIPS STERLING CANCELLOUS 1-4MM 15
|
Facility
OP
|
$405.00
|
|
| Hospital Charge Code |
8026570
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$202.42 |
| Max. Negotiated Rate |
$364.50 |
| Rate for Payer: Aetna of IA Commercial |
$364.50
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$364.50
|
| Rate for Payer: Aetna of IA Medicare |
$230.85
|
| Rate for Payer: Amerigroup Medicaid |
$204.40
|
| Rate for Payer: Amerigroup Medicare |
$204.52
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$303.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$202.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$202.42
|
| Rate for Payer: Medical Associates Commercial |
$303.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$202.50
|
| Rate for Payer: Midlands Choice Commercial |
$283.50
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$205.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$303.75
|
| Rate for Payer: United Healthcare Commercial |
$364.50
|
| Rate for Payer: United Healthcare Managed Medicare |
$238.95
|
|
