|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$402.50
|
|
|
Service Code
|
NDC 00409114102
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$253.57 |
| Max. Negotiated Rate |
$362.25 |
| Rate for Payer: Aetna Commercial |
$342.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.62
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: Cofinity Advantage |
$281.75
|
| Rate for Payer: Cofinity Commercial |
$346.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.00
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.88
|
| Rate for Payer: PHP Commercial |
$342.12
|
| Rate for Payer: Priority Health SBD |
$253.57
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$402.50
|
|
|
Service Code
|
NDC 00409114102
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$158.18 |
| Max. Negotiated Rate |
$362.25 |
| Rate for Payer: Aetna Commercial |
$342.12
|
| Rate for Payer: Aetna Medicare |
$201.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.62
|
| Rate for Payer: BCBS Complete |
$161.00
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: Cofinity Advantage |
$281.75
|
| Rate for Payer: Cofinity Commercial |
$346.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.00
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$322.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.88
|
| Rate for Payer: PHP Commercial |
$342.12
|
| Rate for Payer: Priority Health SBD |
$253.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.62
|
| Rate for Payer: UHC Core |
$209.70
|
| Rate for Payer: UHC Exchange |
$158.18
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$147.75
|
|
|
Service Code
|
NDC 63323009301
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.07 |
| Max. Negotiated Rate |
$132.97 |
| Rate for Payer: Aetna Commercial |
$125.59
|
| Rate for Payer: Aetna Medicare |
$73.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.04
|
| Rate for Payer: BCBS Complete |
$59.10
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cofinity Advantage |
$103.42
|
| Rate for Payer: Cofinity Commercial |
$127.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.20
|
| Rate for Payer: Healthscope Commercial |
$132.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$118.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$110.81
|
| Rate for Payer: PHP Commercial |
$125.59
|
| Rate for Payer: Priority Health SBD |
$93.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$96.04
|
| Rate for Payer: UHC Core |
$76.98
|
| Rate for Payer: UHC Exchange |
$58.07
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$147.75
|
|
|
Service Code
|
NDC 63323009301
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.08 |
| Max. Negotiated Rate |
$132.97 |
| Rate for Payer: Aetna Commercial |
$125.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.04
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cofinity Advantage |
$103.42
|
| Rate for Payer: Cofinity Commercial |
$127.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.20
|
| Rate for Payer: Healthscope Commercial |
$132.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$110.81
|
| Rate for Payer: PHP Commercial |
$125.59
|
| Rate for Payer: Priority Health SBD |
$93.08
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$402.50
|
|
|
Service Code
|
NDC 00409114112
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$158.18 |
| Max. Negotiated Rate |
$362.25 |
| Rate for Payer: Aetna Commercial |
$342.12
|
| Rate for Payer: Aetna Medicare |
$201.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.62
|
| Rate for Payer: BCBS Complete |
$161.00
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: Cofinity Advantage |
$281.75
|
| Rate for Payer: Cofinity Commercial |
$346.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.00
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$322.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.88
|
| Rate for Payer: PHP Commercial |
$342.12
|
| Rate for Payer: Priority Health SBD |
$253.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.62
|
| Rate for Payer: UHC Core |
$209.70
|
| Rate for Payer: UHC Exchange |
$158.18
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$402.50
|
|
|
Service Code
|
NDC 00409114112
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$253.57 |
| Max. Negotiated Rate |
$362.25 |
| Rate for Payer: Aetna Commercial |
$342.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.62
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: Cofinity Advantage |
$281.75
|
| Rate for Payer: Cofinity Commercial |
$346.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.00
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.88
|
| Rate for Payer: PHP Commercial |
$342.12
|
| Rate for Payer: Priority Health SBD |
$253.57
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION (TPN COMPONENT)
|
Facility
|
IP
|
$402.50
|
|
|
Service Code
|
NDC 09900001915
|
| Hospital Charge Code |
300440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$253.57 |
| Max. Negotiated Rate |
$362.25 |
| Rate for Payer: Aetna Commercial |
$342.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.62
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: Cofinity Advantage |
$281.75
|
| Rate for Payer: Cofinity Commercial |
$346.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.00
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.88
|
| Rate for Payer: PHP Commercial |
$342.12
|
| Rate for Payer: Priority Health SBD |
$253.57
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION (TPN COMPONENT)
|
Facility
|
OP
|
$402.50
|
|
|
Service Code
|
NDC 09900001915
|
| Hospital Charge Code |
300440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$158.18 |
| Max. Negotiated Rate |
$362.25 |
| Rate for Payer: Aetna Commercial |
$342.12
|
| Rate for Payer: Aetna Medicare |
$201.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.62
|
| Rate for Payer: BCBS Complete |
$161.00
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: Cofinity Advantage |
$281.75
|
| Rate for Payer: Cofinity Commercial |
$346.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.00
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$322.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$301.88
|
| Rate for Payer: PHP Commercial |
$342.12
|
| Rate for Payer: Priority Health SBD |
$253.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.62
|
| Rate for Payer: UHC Core |
$209.70
|
| Rate for Payer: UHC Exchange |
$158.18
|
|
|
SODIUM CHLORIDE 5 % EYE DROPS
|
Facility
|
IP
|
$25.18
|
|
|
Service Code
|
NDC 17478062312
|
| Hospital Charge Code |
7332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.86 |
| Max. Negotiated Rate |
$22.66 |
| Rate for Payer: Aetna Commercial |
$21.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.37
|
| Rate for Payer: Cash Price |
$20.14
|
| Rate for Payer: Cofinity Advantage |
$17.63
|
| Rate for Payer: Cofinity Commercial |
$21.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.14
|
| Rate for Payer: Healthscope Commercial |
$22.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.89
|
| Rate for Payer: PHP Commercial |
$21.40
|
| Rate for Payer: Priority Health SBD |
$15.86
|
|
|
SODIUM CHLORIDE 5 % EYE DROPS
|
Facility
|
IP
|
$17.82
|
|
|
Service Code
|
NDC 00536125494
|
| Hospital Charge Code |
7332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna Commercial |
$15.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.58
|
| Rate for Payer: Cash Price |
$14.26
|
| Rate for Payer: Cofinity Advantage |
$12.47
|
| Rate for Payer: Cofinity Commercial |
$15.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.26
|
| Rate for Payer: Healthscope Commercial |
$16.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.37
|
| Rate for Payer: PHP Commercial |
$15.15
|
| Rate for Payer: Priority Health SBD |
$11.23
|
|
|
SODIUM CHLORIDE 5 % EYE DROPS
|
Facility
|
OP
|
$17.82
|
|
|
Service Code
|
NDC 00536125494
|
| Hospital Charge Code |
7332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna Commercial |
$15.15
|
| Rate for Payer: Aetna Medicare |
$8.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.58
|
| Rate for Payer: BCBS Complete |
$7.13
|
| Rate for Payer: Cash Price |
$14.26
|
| Rate for Payer: Cofinity Advantage |
$12.47
|
| Rate for Payer: Cofinity Commercial |
$15.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.26
|
| Rate for Payer: Healthscope Commercial |
$16.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.37
|
| Rate for Payer: PHP Commercial |
$15.15
|
| Rate for Payer: Priority Health SBD |
$11.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.58
|
| Rate for Payer: UHC Core |
$9.28
|
| Rate for Payer: UHC Exchange |
$7.00
|
|
|
SODIUM CHLORIDE 5 % EYE DROPS
|
Facility
|
OP
|
$25.18
|
|
|
Service Code
|
NDC 17478062312
|
| Hospital Charge Code |
7332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$22.66 |
| Rate for Payer: Aetna Commercial |
$21.40
|
| Rate for Payer: Aetna Medicare |
$12.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.37
|
| Rate for Payer: BCBS Complete |
$10.07
|
| Rate for Payer: Cash Price |
$20.14
|
| Rate for Payer: Cofinity Advantage |
$17.63
|
| Rate for Payer: Cofinity Commercial |
$21.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.14
|
| Rate for Payer: Healthscope Commercial |
$22.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.89
|
| Rate for Payer: PHP Commercial |
$21.40
|
| Rate for Payer: Priority Health SBD |
$15.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.37
|
| Rate for Payer: UHC Core |
$13.12
|
| Rate for Payer: UHC Exchange |
$9.90
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$19.58
|
|
|
Service Code
|
NDC 57237031915
|
| Hospital Charge Code |
15706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$17.62 |
| Rate for Payer: Aetna Commercial |
$16.64
|
| Rate for Payer: Aetna Medicare |
$9.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.73
|
| Rate for Payer: BCBS Complete |
$7.83
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cofinity Advantage |
$13.71
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.69
|
| Rate for Payer: PHP Commercial |
$16.64
|
| Rate for Payer: Priority Health SBD |
$12.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.73
|
| Rate for Payer: UHC Core |
$10.20
|
| Rate for Payer: UHC Exchange |
$7.69
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$19.58
|
|
|
Service Code
|
NDC 57237031915
|
| Hospital Charge Code |
15706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.34 |
| Max. Negotiated Rate |
$17.62 |
| Rate for Payer: Aetna Commercial |
$16.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.73
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cofinity Advantage |
$13.71
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.69
|
| Rate for Payer: PHP Commercial |
$16.64
|
| Rate for Payer: Priority Health SBD |
$12.34
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$19.58
|
|
|
Service Code
|
NDC 57237031952
|
| Hospital Charge Code |
15706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.34 |
| Max. Negotiated Rate |
$17.62 |
| Rate for Payer: Aetna Commercial |
$16.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.73
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cofinity Advantage |
$13.71
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.69
|
| Rate for Payer: PHP Commercial |
$16.64
|
| Rate for Payer: Priority Health SBD |
$12.34
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$19.58
|
|
|
Service Code
|
NDC 57237031952
|
| Hospital Charge Code |
15706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$17.62 |
| Rate for Payer: Aetna Commercial |
$16.64
|
| Rate for Payer: Aetna Medicare |
$9.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.73
|
| Rate for Payer: BCBS Complete |
$7.83
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cofinity Advantage |
$13.71
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.69
|
| Rate for Payer: PHP Commercial |
$16.64
|
| Rate for Payer: Priority Health SBD |
$12.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.73
|
| Rate for Payer: UHC Core |
$10.20
|
| Rate for Payer: UHC Exchange |
$7.69
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET
|
Facility
|
IP
|
$264.10
|
|
|
Service Code
|
NDC 39328010710
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.38 |
| Max. Negotiated Rate |
$237.69 |
| Rate for Payer: Aetna Commercial |
$224.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.66
|
| Rate for Payer: Cash Price |
$211.28
|
| Rate for Payer: Cofinity Advantage |
$184.87
|
| Rate for Payer: Cofinity Commercial |
$227.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.28
|
| Rate for Payer: Healthscope Commercial |
$237.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$198.07
|
| Rate for Payer: PHP Commercial |
$224.49
|
| Rate for Payer: Priority Health SBD |
$166.38
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET
|
Facility
|
OP
|
$131.91
|
|
|
Service Code
|
NDC 68084076425
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.84 |
| Max. Negotiated Rate |
$118.72 |
| Rate for Payer: Aetna Commercial |
$112.12
|
| Rate for Payer: Aetna Medicare |
$65.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.74
|
| Rate for Payer: BCBS Complete |
$52.76
|
| Rate for Payer: Cash Price |
$105.53
|
| Rate for Payer: Cofinity Advantage |
$92.34
|
| Rate for Payer: Cofinity Commercial |
$113.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.53
|
| Rate for Payer: Healthscope Commercial |
$118.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.93
|
| Rate for Payer: PHP Commercial |
$112.12
|
| Rate for Payer: Priority Health SBD |
$83.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$85.74
|
| Rate for Payer: UHC Core |
$68.73
|
| Rate for Payer: UHC Exchange |
$51.84
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 68084076495
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.86
|
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: Cofinity Advantage |
$3.08
|
| Rate for Payer: Cofinity Commercial |
$3.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.52
|
| Rate for Payer: Healthscope Commercial |
$3.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.30
|
| Rate for Payer: PHP Commercial |
$3.74
|
| Rate for Payer: Priority Health SBD |
$2.77
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET
|
Facility
|
OP
|
$264.10
|
|
|
Service Code
|
NDC 39328010710
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.79 |
| Max. Negotiated Rate |
$237.69 |
| Rate for Payer: Aetna Commercial |
$224.49
|
| Rate for Payer: Aetna Medicare |
$132.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.66
|
| Rate for Payer: BCBS Complete |
$105.64
|
| Rate for Payer: Cash Price |
$211.28
|
| Rate for Payer: Cofinity Advantage |
$184.87
|
| Rate for Payer: Cofinity Commercial |
$227.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.28
|
| Rate for Payer: Healthscope Commercial |
$237.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$211.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$198.07
|
| Rate for Payer: PHP Commercial |
$224.49
|
| Rate for Payer: Priority Health SBD |
$166.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.66
|
| Rate for Payer: UHC Core |
$137.60
|
| Rate for Payer: UHC Exchange |
$103.79
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET
|
Facility
|
OP
|
$299.25
|
|
|
Service Code
|
NDC 64980010401
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.61 |
| Max. Negotiated Rate |
$269.32 |
| Rate for Payer: Aetna Commercial |
$254.36
|
| Rate for Payer: Aetna Medicare |
$149.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.51
|
| Rate for Payer: BCBS Complete |
$119.70
|
| Rate for Payer: Cash Price |
$239.40
|
| Rate for Payer: Cofinity Advantage |
$209.47
|
| Rate for Payer: Cofinity Commercial |
$257.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.40
|
| Rate for Payer: Healthscope Commercial |
$269.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$239.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$254.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$224.44
|
| Rate for Payer: PHP Commercial |
$254.36
|
| Rate for Payer: Priority Health SBD |
$188.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$194.51
|
| Rate for Payer: UHC Core |
$155.91
|
| Rate for Payer: UHC Exchange |
$117.61
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET
|
Facility
|
IP
|
$131.91
|
|
|
Service Code
|
NDC 68084076425
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.10 |
| Max. Negotiated Rate |
$118.72 |
| Rate for Payer: Aetna Commercial |
$112.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.74
|
| Rate for Payer: Cash Price |
$105.53
|
| Rate for Payer: Cofinity Advantage |
$92.34
|
| Rate for Payer: Cofinity Commercial |
$113.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.53
|
| Rate for Payer: Healthscope Commercial |
$118.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.93
|
| Rate for Payer: PHP Commercial |
$112.12
|
| Rate for Payer: Priority Health SBD |
$83.10
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 68084076495
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Medicare |
$2.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.86
|
| Rate for Payer: BCBS Complete |
$1.76
|
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: Cofinity Advantage |
$3.08
|
| Rate for Payer: Cofinity Commercial |
$3.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.52
|
| Rate for Payer: Healthscope Commercial |
$3.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.30
|
| Rate for Payer: PHP Commercial |
$3.74
|
| Rate for Payer: Priority Health SBD |
$2.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.86
|
| Rate for Payer: UHC Core |
$2.29
|
| Rate for Payer: UHC Exchange |
$1.73
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET
|
Facility
|
IP
|
$299.25
|
|
|
Service Code
|
NDC 64980010401
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.53 |
| Max. Negotiated Rate |
$269.32 |
| Rate for Payer: Aetna Commercial |
$254.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.51
|
| Rate for Payer: Cash Price |
$239.40
|
| Rate for Payer: Cofinity Advantage |
$209.47
|
| Rate for Payer: Cofinity Commercial |
$257.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.40
|
| Rate for Payer: Healthscope Commercial |
$269.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$254.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$224.44
|
| Rate for Payer: PHP Commercial |
$254.36
|
| Rate for Payer: Priority Health SBD |
$188.53
|
|
|
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS
|
Facility
|
OP
|
$137.98
|
|
|
Service Code
|
HCPCS J2916
|
| Hospital Charge Code |
24932
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$124.18 |
| Rate for Payer: Aetna Commercial |
$117.28
|
| Rate for Payer: Aetna Medicare |
$68.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.69
|
| Rate for Payer: BCBS Complete |
$55.19
|
| Rate for Payer: BCBS Trust/PPO |
$5.54
|
| Rate for Payer: BCN Commercial |
$5.54
|
| Rate for Payer: Cash Price |
$110.38
|
| Rate for Payer: Cash Price |
$110.38
|
| Rate for Payer: Cofinity Advantage |
$96.59
|
| Rate for Payer: Cofinity Commercial |
$118.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.38
|
| Rate for Payer: Healthscope Commercial |
$124.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$110.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.48
|
| Rate for Payer: PHP Commercial |
$117.28
|
| Rate for Payer: Priority Health SBD |
$86.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.65
|
| Rate for Payer: UHC Core |
$3.65
|
| Rate for Payer: UHC Exchange |
$3.65
|
|
