|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$172.75
|
|
|
Service Code
|
NDC 00338914730
|
| Hospital Charge Code |
116171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$155.48 |
| Rate for Payer: Aetna Commercial |
$146.84
|
| Rate for Payer: Aetna Medicare |
$86.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.29
|
| Rate for Payer: BCBS Complete |
$69.10
|
| Rate for Payer: Cash Price |
$138.20
|
| Rate for Payer: Cofinity Commercial |
$120.92
|
| Rate for Payer: Cofinity Commercial |
$148.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$120.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.20
|
| Rate for Payer: Healthscope Commercial |
$155.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.84
|
| Rate for Payer: PHP Commercial |
$146.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.29
|
| Rate for Payer: Priority Health SBD |
$108.83
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$172.75
|
|
|
Service Code
|
NDC 00338914730
|
| Hospital Charge Code |
116171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.83 |
| Max. Negotiated Rate |
$155.48 |
| Rate for Payer: Aetna Commercial |
$146.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.29
|
| Rate for Payer: Cash Price |
$138.20
|
| Rate for Payer: Cofinity Commercial |
$120.92
|
| Rate for Payer: Cofinity Commercial |
$148.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$120.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.20
|
| Rate for Payer: Healthscope Commercial |
$155.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.84
|
| Rate for Payer: PHP Commercial |
$146.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.29
|
| Rate for Payer: Priority Health SBD |
$108.83
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$55.99
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.27 |
| Max. Negotiated Rate |
$50.39 |
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$10.29
|
| Rate for Payer: BCN Commercial |
$10.29
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$67.19
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Medicare |
$28.00
|
| Rate for Payer: Aetna Medicare |
$29.12
|
| Rate for Payer: Aetna Medicare |
$33.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV ADDITIONAL SOLUTION
|
Facility
|
IP
|
$58.23
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
180629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.68 |
| Max. Negotiated Rate |
$52.41 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV ADDITIONAL SOLUTION
|
Facility
|
OP
|
$58.23
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
180629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$52.41 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Medicare |
$29.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV BOLUS FROM BAG
|
Facility
|
OP
|
$10.29
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
500616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$10.29 |
| Rate for Payer: BCBS Trust/PPO |
$10.29
|
| Rate for Payer: BCN Commercial |
$10.29
|
|
|
DEXTROSE 5% IN WATER INTRAVENOUS SOLUTION (DOSE, ADMIN OVER & INDICATION REQUIRED)
|
Facility
|
OP
|
$67.19
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
301087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Medicare |
$33.60
|
| Rate for Payer: Aetna Medicare |
$28.00
|
| Rate for Payer: Aetna Medicare |
$29.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health SBD |
$36.68
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: Priority Health SBD |
$42.33
|
|
|
DEXTROSE 5% IN WATER INTRAVENOUS SOLUTION (DOSE, ADMIN OVER & INDICATION REQUIRED)
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
301087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$10.29
|
| Rate for Payer: BCN Commercial |
$10.29
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
OP
|
$55.99
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$50.39 |
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Medicare |
$33.60
|
| Rate for Payer: Aetna Medicare |
$28.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$35.27
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$55.99
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.27 |
| Max. Negotiated Rate |
$50.39 |
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: Priority Health SBD |
$42.33
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$10.29
|
| Rate for Payer: BCN Commercial |
$10.29
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5%-LACTATED RINGERS IV BOLUS FROM BAG
|
Facility
|
OP
|
$12.78
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
500632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.78 |
| Max. Negotiated Rate |
$12.78 |
| Rate for Payer: BCBS Trust/PPO |
$12.78
|
| Rate for Payer: BCN Commercial |
$12.78
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$110.16
|
|
|
Service Code
|
NDC 00338071906
|
| Hospital Charge Code |
2367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.06 |
| Max. Negotiated Rate |
$99.14 |
| Rate for Payer: Aetna Commercial |
$93.64
|
| Rate for Payer: Aetna Medicare |
$55.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.60
|
| Rate for Payer: BCBS Complete |
$44.06
|
| Rate for Payer: Cash Price |
$88.13
|
| Rate for Payer: Cofinity Commercial |
$77.11
|
| Rate for Payer: Cofinity Commercial |
$94.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.13
|
| Rate for Payer: Healthscope Commercial |
$99.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.64
|
| Rate for Payer: PHP Commercial |
$93.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.60
|
| Rate for Payer: Priority Health SBD |
$69.40
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$110.16
|
|
|
Service Code
|
NDC 00338071906
|
| Hospital Charge Code |
2367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.40 |
| Max. Negotiated Rate |
$99.14 |
| Rate for Payer: Aetna Commercial |
$93.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.60
|
| Rate for Payer: Cash Price |
$88.13
|
| Rate for Payer: Cofinity Commercial |
$77.11
|
| Rate for Payer: Cofinity Commercial |
$94.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.13
|
| Rate for Payer: Healthscope Commercial |
$99.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.64
|
| Rate for Payer: PHP Commercial |
$93.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.60
|
| Rate for Payer: Priority Health SBD |
$69.40
|
|
|
DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna Medicare |
$45.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.50
|
| Rate for Payer: BCBS Complete |
$36.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cofinity Commercial |
$77.40
|
| Rate for Payer: Cofinity Commercial |
$63.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.00
|
| Rate for Payer: Healthscope Commercial |
$81.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.50
|
| Rate for Payer: PHP Commercial |
$76.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.50
|
| Rate for Payer: Priority Health SBD |
$56.70
|
|
|
DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.50
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cofinity Commercial |
$63.00
|
| Rate for Payer: Cofinity Commercial |
$77.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.00
|
| Rate for Payer: Healthscope Commercial |
$81.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.50
|
| Rate for Payer: PHP Commercial |
$76.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.50
|
| Rate for Payer: Priority Health SBD |
$56.70
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION
|
Facility
|
IP
|
$182.50
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
27735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.98 |
| Max. Negotiated Rate |
$164.25 |
| Rate for Payer: Aetna Commercial |
$155.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.62
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cofinity Commercial |
$127.75
|
| Rate for Payer: Cofinity Commercial |
$156.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.00
|
| Rate for Payer: Healthscope Commercial |
$164.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.12
|
| Rate for Payer: PHP Commercial |
$155.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.62
|
| Rate for Payer: Priority Health SBD |
$114.98
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION
|
Facility
|
OP
|
$182.50
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
27735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$164.25 |
| Rate for Payer: Aetna Commercial |
$155.12
|
| Rate for Payer: Aetna Medicare |
$91.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.62
|
| Rate for Payer: BCBS Complete |
$73.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cofinity Commercial |
$127.75
|
| Rate for Payer: Cofinity Commercial |
$156.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.00
|
| Rate for Payer: Healthscope Commercial |
$164.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.12
|
| Rate for Payer: PHP Commercial |
$155.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.62
|
| Rate for Payer: Priority Health SBD |
$114.98
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
OP
|
$58.75
|
|
|
Service Code
|
NDC 00172392760
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna Medicare |
$29.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: BCBS Complete |
$23.50
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.19
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 00172392760
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.01 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.19
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
IP
|
$1.58
|
|
|
Service Code
|
NDC 51079028601
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.03
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Commercial |
$1.11
|
| Rate for Payer: Cofinity Commercial |
$1.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.34
|
| Rate for Payer: PHP Commercial |
$1.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.03
|
| Rate for Payer: Priority Health SBD |
$1.00
|
|
