|
LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE
|
Facility
|
OP
|
$9,573.02
|
|
|
Service Code
|
CPT 50590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$561.56 |
| Max. Negotiated Rate |
$9,573.02 |
| Rate for Payer: Aetna Medicare |
$3,226.04
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,877.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,877.45
|
| Rate for Payer: BCBS Complete |
$1,781.77
|
| Rate for Payer: BCBS MAPPO |
$3,101.96
|
| Rate for Payer: BCBS Trust/PPO |
$1,626.69
|
| Rate for Payer: BCN Medicare Advantage |
$3,101.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,101.96
|
| Rate for Payer: Mclaren Medicaid |
$1,696.77
|
| Rate for Payer: Mclaren Medicare |
$3,101.96
|
| Rate for Payer: Meridian Medicaid |
$1,781.77
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,257.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,567.25
|
| Rate for Payer: PACE Medicare |
$2,946.86
|
| Rate for Payer: PACE SWMI |
$3,101.96
|
| Rate for Payer: PHP Medicare Advantage |
$3,101.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,696.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,573.02
|
| Rate for Payer: Priority Health Medicare |
$3,101.96
|
| Rate for Payer: Priority Health Narrow Network |
$7,658.42
|
| Rate for Payer: Railroad Medicare Medicare |
$3,101.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$617.72
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,101.96
|
| Rate for Payer: UHC Exchange |
$561.56
|
| Rate for Payer: UHC Medicare Advantage |
$3,195.02
|
| Rate for Payer: VA VA |
$3,101.96
|
|
|
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT
|
Facility
|
IP
|
$203,476.49
|
|
|
Service Code
|
MS-DRG 005
|
| Min. Negotiated Rate |
$71,279.72 |
| Max. Negotiated Rate |
$203,476.49 |
| Rate for Payer: Aetna Medicare |
$78,032.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$93,789.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$93,789.10
|
| Rate for Payer: BCBS MAPPO |
$75,031.28
|
| Rate for Payer: BCBS Trust/PPO |
$203,476.49
|
| Rate for Payer: BCN Medicare Advantage |
$75,031.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$75,031.28
|
| Rate for Payer: Mclaren Medicare |
$75,031.28
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$78,782.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$86,285.97
|
| Rate for Payer: PACE Medicare |
$71,279.72
|
| Rate for Payer: PACE SWMI |
$75,031.28
|
| Rate for Payer: PHP Medicare Advantage |
$75,031.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$148,521.67
|
| Rate for Payer: Priority Health Medicare |
$75,031.28
|
| Rate for Payer: Priority Health Narrow Network |
$118,817.34
|
| Rate for Payer: Railroad Medicare Medicare |
$75,031.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157,878.90
|
| Rate for Payer: UHC Core |
$96,876.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$75,031.28
|
| Rate for Payer: UHC Exchange |
$103,758.75
|
| Rate for Payer: UHC Medicare Advantage |
$77,282.22
|
| Rate for Payer: VA VA |
$75,031.28
|
|
|
LIVER TRANSPLANT WITHOUT MCC
|
Facility
|
IP
|
$78,277.25
|
|
|
Service Code
|
MS-DRG 006
|
| Min. Negotiated Rate |
$33,560.73 |
| Max. Negotiated Rate |
$78,277.25 |
| Rate for Payer: Aetna Medicare |
$36,740.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$44,158.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$44,158.85
|
| Rate for Payer: BCBS MAPPO |
$35,327.08
|
| Rate for Payer: BCBS Trust/PPO |
$78,277.25
|
| Rate for Payer: BCN Medicare Advantage |
$35,327.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$35,327.08
|
| Rate for Payer: Mclaren Medicare |
$35,327.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$37,093.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40,626.14
|
| Rate for Payer: PACE Medicare |
$33,560.73
|
| Rate for Payer: PACE SWMI |
$35,327.08
|
| Rate for Payer: PHP Medicare Advantage |
$35,327.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$69,409.13
|
| Rate for Payer: Priority Health Medicare |
$35,327.08
|
| Rate for Payer: Priority Health Narrow Network |
$55,527.30
|
| Rate for Payer: Railroad Medicare Medicare |
$35,327.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$73,782.07
|
| Rate for Payer: UHC Core |
$45,273.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$35,327.08
|
| Rate for Payer: UHC Exchange |
$48,489.92
|
| Rate for Payer: UHC Medicare Advantage |
$36,386.89
|
| Rate for Payer: VA VA |
$35,327.08
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC
|
Facility
|
IP
|
$35,046.56
|
|
|
Service Code
|
MS-DRG 496
|
| Min. Negotiated Rate |
$14,065.98 |
| Max. Negotiated Rate |
$35,046.56 |
| Rate for Payer: Aetna Medicare |
$15,398.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,507.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,507.86
|
| Rate for Payer: BCBS MAPPO |
$14,806.29
|
| Rate for Payer: BCBS Trust/PPO |
$35,046.56
|
| Rate for Payer: BCN Medicare Advantage |
$14,806.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,806.29
|
| Rate for Payer: Mclaren Medicare |
$14,806.29
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15,546.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17,027.23
|
| Rate for Payer: PACE Medicare |
$14,065.98
|
| Rate for Payer: PACE SWMI |
$14,806.29
|
| Rate for Payer: PHP Medicare Advantage |
$14,806.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28,520.47
|
| Rate for Payer: Priority Health Medicare |
$14,806.29
|
| Rate for Payer: Priority Health Narrow Network |
$22,816.38
|
| Rate for Payer: Railroad Medicare Medicare |
$14,806.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$30,317.33
|
| Rate for Payer: UHC Core |
$18,603.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$14,806.29
|
| Rate for Payer: UHC Exchange |
$19,924.69
|
| Rate for Payer: UHC Medicare Advantage |
$15,250.48
|
| Rate for Payer: VA VA |
$14,806.29
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC
|
Facility
|
IP
|
$79,878.06
|
|
|
Service Code
|
MS-DRG 495
|
| Min. Negotiated Rate |
$24,969.59 |
| Max. Negotiated Rate |
$79,878.06 |
| Rate for Payer: Aetna Medicare |
$27,335.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$32,854.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$32,854.72
|
| Rate for Payer: BCBS MAPPO |
$26,283.78
|
| Rate for Payer: BCBS Trust/PPO |
$79,878.06
|
| Rate for Payer: BCN Medicare Advantage |
$26,283.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26,283.78
|
| Rate for Payer: Mclaren Medicare |
$26,283.78
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$27,597.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30,226.35
|
| Rate for Payer: PACE Medicare |
$24,969.59
|
| Rate for Payer: PACE SWMI |
$26,283.78
|
| Rate for Payer: PHP Medicare Advantage |
$26,283.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$51,389.93
|
| Rate for Payer: Priority Health Medicare |
$26,283.78
|
| Rate for Payer: Priority Health Narrow Network |
$41,111.94
|
| Rate for Payer: Railroad Medicare Medicare |
$26,283.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$54,627.62
|
| Rate for Payer: UHC Core |
$33,520.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$26,283.78
|
| Rate for Payer: UHC Exchange |
$35,901.53
|
| Rate for Payer: UHC Medicare Advantage |
$27,072.29
|
| Rate for Payer: VA VA |
$26,283.78
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$23,893.59
|
|
|
Service Code
|
MS-DRG 497
|
| Min. Negotiated Rate |
$10,233.94 |
| Max. Negotiated Rate |
$23,893.59 |
| Rate for Payer: Aetna Medicare |
$11,203.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,465.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,465.71
|
| Rate for Payer: BCBS MAPPO |
$10,772.57
|
| Rate for Payer: BCBS Trust/PPO |
$23,893.59
|
| Rate for Payer: BCN Medicare Advantage |
$10,772.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,772.57
|
| Rate for Payer: Mclaren Medicare |
$10,772.57
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,311.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,388.46
|
| Rate for Payer: PACE Medicare |
$10,233.94
|
| Rate for Payer: PACE SWMI |
$10,772.57
|
| Rate for Payer: PHP Medicare Advantage |
$10,772.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,483.08
|
| Rate for Payer: Priority Health Medicare |
$10,772.57
|
| Rate for Payer: Priority Health Narrow Network |
$16,386.46
|
| Rate for Payer: Railroad Medicare Medicare |
$10,772.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21,773.56
|
| Rate for Payer: UHC Core |
$13,360.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,772.57
|
| Rate for Payer: UHC Exchange |
$14,309.69
|
| Rate for Payer: UHC Medicare Advantage |
$11,095.75
|
| Rate for Payer: VA VA |
$10,772.57
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC
|
Facility
|
IP
|
$43,979.49
|
|
|
Service Code
|
MS-DRG 498
|
| Min. Negotiated Rate |
$18,331.77 |
| Max. Negotiated Rate |
$43,979.49 |
| Rate for Payer: Aetna Medicare |
$20,068.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,120.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,120.75
|
| Rate for Payer: BCBS MAPPO |
$19,296.60
|
| Rate for Payer: BCBS Trust/PPO |
$43,979.49
|
| Rate for Payer: BCN Medicare Advantage |
$19,296.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,296.60
|
| Rate for Payer: Mclaren Medicare |
$19,296.60
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$20,261.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,191.09
|
| Rate for Payer: PACE Medicare |
$18,331.77
|
| Rate for Payer: PACE SWMI |
$19,296.60
|
| Rate for Payer: PHP Medicare Advantage |
$19,296.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37,467.64
|
| Rate for Payer: Priority Health Medicare |
$19,296.60
|
| Rate for Payer: Priority Health Narrow Network |
$29,974.11
|
| Rate for Payer: Railroad Medicare Medicare |
$19,296.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39,828.19
|
| Rate for Payer: UHC Core |
$24,438.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$19,296.60
|
| Rate for Payer: UHC Exchange |
$26,175.28
|
| Rate for Payer: UHC Medicare Advantage |
$19,875.50
|
| Rate for Payer: VA VA |
$19,296.60
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$19,835.56
|
|
|
Service Code
|
MS-DRG 499
|
| Min. Negotiated Rate |
$9,292.52 |
| Max. Negotiated Rate |
$19,835.56 |
| Rate for Payer: Aetna Medicare |
$10,172.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,227.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,227.00
|
| Rate for Payer: BCBS MAPPO |
$9,781.60
|
| Rate for Payer: BCBS Trust/PPO |
$19,835.56
|
| Rate for Payer: BCN Medicare Advantage |
$9,781.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,781.60
|
| Rate for Payer: Mclaren Medicare |
$9,781.60
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,270.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,248.84
|
| Rate for Payer: PACE Medicare |
$9,292.52
|
| Rate for Payer: PACE SWMI |
$9,781.60
|
| Rate for Payer: PHP Medicare Advantage |
$9,781.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,508.53
|
| Rate for Payer: Priority Health Medicare |
$9,781.60
|
| Rate for Payer: Priority Health Narrow Network |
$14,806.82
|
| Rate for Payer: Railroad Medicare Medicare |
$9,781.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,674.61
|
| Rate for Payer: UHC Core |
$12,072.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,781.60
|
| Rate for Payer: UHC Exchange |
$12,930.25
|
| Rate for Payer: UHC Medicare Advantage |
$10,075.05
|
| Rate for Payer: VA VA |
$9,781.60
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
IP
|
$21.84
|
|
|
Service Code
|
NDC 45013404
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.20
|
| Rate for Payer: Cash Price |
$17.47
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Cofinity Commercial |
$18.78
|
| Rate for Payer: Healthscope Commercial |
$19.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.56
|
| Rate for Payer: PHP Commercial |
$18.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.29
|
| Rate for Payer: Priority Health SBD |
$13.76
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
OP
|
$242.88
|
|
|
Service Code
|
NDC 60687-229-01
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.15 |
| Max. Negotiated Rate |
$218.59 |
| Rate for Payer: Aetna Commercial |
$206.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.87
|
| Rate for Payer: BCBS Complete |
$97.15
|
| Rate for Payer: Cash Price |
$194.30
|
| Rate for Payer: Cofinity Commercial |
$170.02
|
| Rate for Payer: Cofinity Commercial |
$208.88
|
| Rate for Payer: Healthscope Commercial |
$218.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.45
|
| Rate for Payer: PHP Commercial |
$206.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.02
|
| Rate for Payer: Priority Health SBD |
$153.01
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$242.88
|
|
|
Service Code
|
NDC 60687-229-01
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.01 |
| Max. Negotiated Rate |
$218.59 |
| Rate for Payer: Aetna Commercial |
$206.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.87
|
| Rate for Payer: Cash Price |
$194.30
|
| Rate for Payer: Cofinity Commercial |
$170.02
|
| Rate for Payer: Cofinity Commercial |
$208.88
|
| Rate for Payer: Healthscope Commercial |
$218.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.45
|
| Rate for Payer: PHP Commercial |
$206.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.02
|
| Rate for Payer: Priority Health SBD |
$153.01
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$2.43
|
|
|
Service Code
|
NDC 60687-229-11
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$2.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.58
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$1.70
|
| Rate for Payer: Cofinity Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.07
|
| Rate for Payer: PHP Commercial |
$2.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.53
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$324.90
|
|
|
Service Code
|
NDC 0378-2100-01
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.69 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.43
|
| Rate for Payer: Priority Health SBD |
$204.69
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
OP
|
$2.43
|
|
|
Service Code
|
NDC 60687-229-11
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$2.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.58
|
| Rate for Payer: BCBS Complete |
$0.97
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$1.70
|
| Rate for Payer: Cofinity Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.07
|
| Rate for Payer: PHP Commercial |
$2.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.53
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$3.25
|
|
|
Service Code
|
NDC 51079-690-01
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna Commercial |
$2.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.11
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cofinity Commercial |
$2.28
|
| Rate for Payer: Cofinity Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$2.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.76
|
| Rate for Payer: PHP Commercial |
$2.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.28
|
| Rate for Payer: Priority Health SBD |
$2.05
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$324.96
|
|
|
Service Code
|
NDC 51079-690-20
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.72 |
| Max. Negotiated Rate |
$292.46 |
| Rate for Payer: Aetna Commercial |
$276.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.22
|
| Rate for Payer: Cash Price |
$259.97
|
| Rate for Payer: Cofinity Commercial |
$227.47
|
| Rate for Payer: Cofinity Commercial |
$279.47
|
| Rate for Payer: Healthscope Commercial |
$292.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.22
|
| Rate for Payer: PHP Commercial |
$276.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.47
|
| Rate for Payer: Priority Health SBD |
$204.72
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
OP
|
$211.85
|
|
|
Service Code
|
NDC 0904-6852-61
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.74 |
| Max. Negotiated Rate |
$190.66 |
| Rate for Payer: Aetna Commercial |
$180.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.70
|
| Rate for Payer: BCBS Complete |
$84.74
|
| Rate for Payer: Cash Price |
$169.48
|
| Rate for Payer: Cofinity Commercial |
$148.30
|
| Rate for Payer: Cofinity Commercial |
$182.19
|
| Rate for Payer: Healthscope Commercial |
$190.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$180.07
|
| Rate for Payer: PHP Commercial |
$180.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.30
|
| Rate for Payer: Priority Health SBD |
$133.47
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$2.41
|
|
|
Service Code
|
NDC 51079-246-01
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna Commercial |
$2.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.57
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Cofinity Commercial |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$2.07
|
| Rate for Payer: Healthscope Commercial |
$2.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.05
|
| Rate for Payer: PHP Commercial |
$2.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health SBD |
$1.52
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$240.35
|
|
|
Service Code
|
NDC 51079-246-20
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.42 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$168.24
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.24
|
| Rate for Payer: Priority Health SBD |
$151.42
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 50268-489-11
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.96
|
| Rate for Payer: Priority Health SBD |
$2.66
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$62.04
|
|
|
Service Code
|
NDC 0904-6852-07
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$55.84 |
| Rate for Payer: Aetna Commercial |
$52.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.33
|
| Rate for Payer: Cash Price |
$49.63
|
| Rate for Payer: Cofinity Commercial |
$43.43
|
| Rate for Payer: Cofinity Commercial |
$53.35
|
| Rate for Payer: Healthscope Commercial |
$55.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.73
|
| Rate for Payer: PHP Commercial |
$52.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.43
|
| Rate for Payer: Priority Health SBD |
$39.09
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 68084-248-11
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.22 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.92
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health SBD |
$150.22
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$211.50
|
|
|
Service Code
|
NDC 50268-489-15
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.24 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna Commercial |
$179.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.48
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cofinity Commercial |
$148.05
|
| Rate for Payer: Cofinity Commercial |
$181.89
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.78
|
| Rate for Payer: PHP Commercial |
$179.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.05
|
| Rate for Payer: Priority Health SBD |
$133.24
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 68084-248-01
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.22 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.92
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health SBD |
$150.22
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$211.85
|
|
|
Service Code
|
NDC 0904-6852-61
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.47 |
| Max. Negotiated Rate |
$190.66 |
| Rate for Payer: Aetna Commercial |
$180.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.70
|
| Rate for Payer: Cash Price |
$169.48
|
| Rate for Payer: Cofinity Commercial |
$148.30
|
| Rate for Payer: Cofinity Commercial |
$182.19
|
| Rate for Payer: Healthscope Commercial |
$190.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$180.07
|
| Rate for Payer: PHP Commercial |
$180.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.30
|
| Rate for Payer: Priority Health SBD |
$133.47
|
|
