|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC
|
Facility
|
IP
|
$31,506.77
|
|
|
Service Code
|
MS-DRG 841
|
| Min. Negotiated Rate |
$11,233.50 |
| Max. Negotiated Rate |
$31,506.77 |
| Rate for Payer: Aetna Medicare |
$12,297.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,780.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,780.92
|
| Rate for Payer: BCBS MAPPO |
$11,824.74
|
| Rate for Payer: BCBS Trust/PPO |
$31,506.77
|
| Rate for Payer: BCN Medicare Advantage |
$11,824.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,824.74
|
| Rate for Payer: Mclaren Medicare |
$11,824.74
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,415.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,598.45
|
| Rate for Payer: PACE Medicare |
$11,233.50
|
| Rate for Payer: PACE SWMI |
$11,824.74
|
| Rate for Payer: PHP Medicare Advantage |
$11,824.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,579.60
|
| Rate for Payer: Priority Health Medicare |
$11,824.74
|
| Rate for Payer: Priority Health Narrow Network |
$18,063.68
|
| Rate for Payer: Railroad Medicare Medicare |
$11,824.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,002.17
|
| Rate for Payer: UHC Core |
$14,727.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,824.74
|
| Rate for Payer: UHC Exchange |
$15,774.34
|
| Rate for Payer: UHC Medicare Advantage |
$12,179.48
|
| Rate for Payer: VA VA |
$11,824.74
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC
|
Facility
|
IP
|
$67,168.19
|
|
|
Service Code
|
MS-DRG 840
|
| Min. Negotiated Rate |
$21,849.77 |
| Max. Negotiated Rate |
$67,168.19 |
| Rate for Payer: Aetna Medicare |
$23,919.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28,749.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28,749.70
|
| Rate for Payer: BCBS MAPPO |
$22,999.76
|
| Rate for Payer: BCBS Trust/PPO |
$67,168.19
|
| Rate for Payer: BCN Medicare Advantage |
$22,999.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22,999.76
|
| Rate for Payer: Mclaren Medicare |
$22,999.76
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$24,149.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26,449.72
|
| Rate for Payer: PACE Medicare |
$21,849.77
|
| Rate for Payer: PACE SWMI |
$22,999.76
|
| Rate for Payer: PHP Medicare Advantage |
$22,999.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$44,846.37
|
| Rate for Payer: Priority Health Medicare |
$22,999.76
|
| Rate for Payer: Priority Health Narrow Network |
$35,877.10
|
| Rate for Payer: Railroad Medicare Medicare |
$22,999.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47,671.80
|
| Rate for Payer: UHC Core |
$29,251.87
|
| Rate for Payer: UHC Dual Complete DSNP |
$22,999.76
|
| Rate for Payer: UHC Exchange |
$31,330.13
|
| Rate for Payer: UHC Medicare Advantage |
$23,689.75
|
| Rate for Payer: VA VA |
$22,999.76
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC
|
Facility
|
IP
|
$41,735.28
|
|
|
Service Code
|
MS-DRG 824
|
| Min. Negotiated Rate |
$15,744.93 |
| Max. Negotiated Rate |
$41,735.28 |
| Rate for Payer: Aetna Medicare |
$17,236.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,717.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,717.01
|
| Rate for Payer: BCBS MAPPO |
$16,573.61
|
| Rate for Payer: BCBS Trust/PPO |
$41,735.28
|
| Rate for Payer: BCN Medicare Advantage |
$16,573.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,573.61
|
| Rate for Payer: Mclaren Medicare |
$16,573.61
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,402.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,059.65
|
| Rate for Payer: PACE Medicare |
$15,744.93
|
| Rate for Payer: PACE SWMI |
$16,573.61
|
| Rate for Payer: PHP Medicare Advantage |
$16,573.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32,041.94
|
| Rate for Payer: Priority Health Medicare |
$16,573.61
|
| Rate for Payer: Priority Health Narrow Network |
$25,633.55
|
| Rate for Payer: Railroad Medicare Medicare |
$16,573.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34,060.66
|
| Rate for Payer: UHC Core |
$20,899.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,573.61
|
| Rate for Payer: UHC Exchange |
$22,384.82
|
| Rate for Payer: UHC Medicare Advantage |
$17,070.82
|
| Rate for Payer: VA VA |
$16,573.61
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC
|
Facility
|
IP
|
$83,762.61
|
|
|
Service Code
|
MS-DRG 823
|
| Min. Negotiated Rate |
$31,268.75 |
| Max. Negotiated Rate |
$83,762.61 |
| Rate for Payer: Aetna Medicare |
$34,231.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$41,143.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$41,143.09
|
| Rate for Payer: BCBS MAPPO |
$32,914.47
|
| Rate for Payer: BCBS Trust/PPO |
$83,762.61
|
| Rate for Payer: BCN Medicare Advantage |
$32,914.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$32,914.47
|
| Rate for Payer: Mclaren Medicare |
$32,914.47
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$34,560.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37,851.64
|
| Rate for Payer: PACE Medicare |
$31,268.75
|
| Rate for Payer: PACE SWMI |
$32,914.47
|
| Rate for Payer: PHP Medicare Advantage |
$32,914.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$64,601.90
|
| Rate for Payer: Priority Health Medicare |
$32,914.47
|
| Rate for Payer: Priority Health Narrow Network |
$51,681.52
|
| Rate for Payer: Railroad Medicare Medicare |
$32,914.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68,671.98
|
| Rate for Payer: UHC Core |
$42,137.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$32,914.47
|
| Rate for Payer: UHC Exchange |
$45,131.55
|
| Rate for Payer: UHC Medicare Advantage |
$33,901.90
|
| Rate for Payer: VA VA |
$32,914.47
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$30,997.32
|
|
|
Service Code
|
MS-DRG 825
|
| Min. Negotiated Rate |
$9,303.46 |
| Max. Negotiated Rate |
$30,997.32 |
| Rate for Payer: Aetna Medicare |
$10,184.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,241.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,241.40
|
| Rate for Payer: BCBS MAPPO |
$9,793.12
|
| Rate for Payer: BCBS Trust/PPO |
$30,997.32
|
| Rate for Payer: BCN Medicare Advantage |
$9,793.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,793.12
|
| Rate for Payer: Mclaren Medicare |
$9,793.12
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,282.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,262.09
|
| Rate for Payer: PACE Medicare |
$9,303.46
|
| Rate for Payer: PACE SWMI |
$9,793.12
|
| Rate for Payer: PHP Medicare Advantage |
$9,793.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,531.49
|
| Rate for Payer: Priority Health Medicare |
$9,793.12
|
| Rate for Payer: Priority Health Narrow Network |
$14,825.19
|
| Rate for Payer: Railroad Medicare Medicare |
$9,793.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,699.02
|
| Rate for Payer: UHC Core |
$12,087.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,793.12
|
| Rate for Payer: UHC Exchange |
$12,946.29
|
| Rate for Payer: UHC Medicare Advantage |
$10,086.91
|
| Rate for Payer: VA VA |
$9,793.12
|
|
|
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC
|
Facility
|
IP
|
$20,068.33
|
|
|
Service Code
|
MS-DRG 842
|
| Min. Negotiated Rate |
$7,764.09 |
| Max. Negotiated Rate |
$20,068.33 |
| Rate for Payer: Aetna Medicare |
$8,499.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,215.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,215.91
|
| Rate for Payer: BCBS MAPPO |
$8,172.73
|
| Rate for Payer: BCBS Trust/PPO |
$20,068.33
|
| Rate for Payer: BCN Medicare Advantage |
$8,172.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,172.73
|
| Rate for Payer: Mclaren Medicare |
$8,172.73
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,581.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,398.64
|
| Rate for Payer: PACE Medicare |
$7,764.09
|
| Rate for Payer: PACE SWMI |
$8,172.73
|
| Rate for Payer: PHP Medicare Advantage |
$8,172.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,302.75
|
| Rate for Payer: Priority Health Medicare |
$8,172.73
|
| Rate for Payer: Priority Health Narrow Network |
$12,242.20
|
| Rate for Payer: Railroad Medicare Medicare |
$8,172.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,266.87
|
| Rate for Payer: UHC Core |
$9,981.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$8,172.73
|
| Rate for Payer: UHC Exchange |
$10,690.66
|
| Rate for Payer: UHC Medicare Advantage |
$8,417.91
|
| Rate for Payer: VA VA |
$8,172.73
|
|
|
LYSIS OF LABIAL ADHESIONS
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 56441
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$154.23 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,893.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,477.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,477.26
|
| Rate for Payer: BCBS Complete |
$1,597.87
|
| Rate for Payer: BCBS MAPPO |
$2,781.81
|
| Rate for Payer: BCBS Trust/PPO |
$925.58
|
| Rate for Payer: BCN Medicare Advantage |
$2,781.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,781.81
|
| Rate for Payer: Mclaren Medicaid |
$1,521.65
|
| Rate for Payer: Mclaren Medicare |
$2,781.81
|
| Rate for Payer: Meridian Medicaid |
$1,597.87
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,920.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,199.08
|
| Rate for Payer: PACE Medicare |
$2,642.72
|
| Rate for Payer: PACE SWMI |
$2,781.81
|
| Rate for Payer: PHP Medicare Advantage |
$2,781.81
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,521.65
|
| Rate for Payer: Priority Health Medicare |
$2,781.81
|
| Rate for Payer: Railroad Medicare Medicare |
$2,781.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.65
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,781.81
|
| Rate for Payer: UHC Exchange |
$154.23
|
| Rate for Payer: UHC Medicare Advantage |
$2,865.26
|
| Rate for Payer: VA VA |
$2,781.81
|
|
|
LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS
|
Facility
|
OP
|
$5,561.92
|
|
|
Service Code
|
CPT 54162
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$197.12 |
| Max. Negotiated Rate |
$5,561.92 |
| Rate for Payer: Aetna Medicare |
$1,884.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,265.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,265.42
|
| Rate for Payer: BCBS Complete |
$1,041.01
|
| Rate for Payer: BCBS MAPPO |
$1,812.34
|
| Rate for Payer: BCBS Trust/PPO |
$1,049.88
|
| Rate for Payer: BCN Medicare Advantage |
$1,812.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,812.34
|
| Rate for Payer: Mclaren Medicaid |
$991.35
|
| Rate for Payer: Mclaren Medicare |
$1,812.34
|
| Rate for Payer: Meridian Medicaid |
$1,041.01
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,902.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,084.19
|
| Rate for Payer: PACE Medicare |
$1,721.72
|
| Rate for Payer: PACE SWMI |
$1,812.34
|
| Rate for Payer: PHP Medicare Advantage |
$1,812.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$991.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,561.92
|
| Rate for Payer: Priority Health Medicare |
$1,812.34
|
| Rate for Payer: Priority Health Narrow Network |
$4,449.54
|
| Rate for Payer: Railroad Medicare Medicare |
$1,812.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$216.83
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,812.34
|
| Rate for Payer: UHC Exchange |
$197.12
|
| Rate for Payer: UHC Medicare Advantage |
$1,866.71
|
| Rate for Payer: VA VA |
$1,812.34
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 4329255738
|
| Hospital Charge Code |
4716
|
|
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: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.12
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
IP
|
$65.80
|
|
|
Service Code
|
NDC 3160401269
|
| Hospital Charge Code |
4716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.45 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.93
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.06
|
| Rate for Payer: Priority Health SBD |
$41.45
|
|
|
MAGNESIUM 250 MG (AS MAGNESIUM OXIDE) TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 761028320
|
| Hospital Charge Code |
4716
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.10 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna Commercial |
$91.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.26
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.88
|
| Rate for Payer: PHP Commercial |
$91.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.67
|
| Rate for Payer: Priority Health SBD |
$68.10
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 71399-7889-1
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.26
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$12.12
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.72
|
| Rate for Payer: PHP Commercial |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.12
|
| Rate for Payer: Priority Health SBD |
$10.91
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 71399-0051-1
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.26
|
| Rate for Payer: Cash Price |
$13.86
|
| Rate for Payer: Cofinity Commercial |
$12.12
|
| Rate for Payer: Cofinity Commercial |
$14.90
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.72
|
| Rate for Payer: PHP Commercial |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.12
|
| Rate for Payer: Priority Health SBD |
$10.91
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$8.64
|
|
|
Service Code
|
NDC 0121-0431-30
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.44 |
| Max. Negotiated Rate |
$7.78 |
| Rate for Payer: Aetna Commercial |
$7.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.62
|
| Rate for Payer: Cash Price |
$6.91
|
| Rate for Payer: Cofinity Commercial |
$6.05
|
| Rate for Payer: Cofinity Commercial |
$7.43
|
| Rate for Payer: Healthscope Commercial |
$7.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.34
|
| Rate for Payer: PHP Commercial |
$7.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.05
|
| Rate for Payer: Priority Health SBD |
$5.44
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 0904-6846-73
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna Commercial |
$6.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.20
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cofinity Commercial |
$5.60
|
| Rate for Payer: Cofinity Commercial |
$6.88
|
| Rate for Payer: Healthscope Commercial |
$7.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.80
|
| Rate for Payer: PHP Commercial |
$6.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.60
|
| Rate for Payer: Priority Health SBD |
$5.04
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 6498033990
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna Commercial |
$1.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.95
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cofinity Commercial |
$1.02
|
| Rate for Payer: Cofinity Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.24
|
| Rate for Payer: PHP Commercial |
$1.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.02
|
| Rate for Payer: Priority Health SBD |
$0.92
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
NDC 3786478599
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.88 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna Commercial |
$149.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.40
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Cofinity Commercial |
$123.20
|
| Rate for Payer: Cofinity Commercial |
$151.36
|
| Rate for Payer: Healthscope Commercial |
$158.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$149.60
|
| Rate for Payer: PHP Commercial |
$149.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.20
|
| Rate for Payer: Priority Health SBD |
$110.88
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$252.00
|
|
|
Service Code
|
NDC 1000670028
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.76 |
| Max. Negotiated Rate |
$226.80 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.80
|
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: Cofinity Commercial |
$176.40
|
| Rate for Payer: Cofinity Commercial |
$216.72
|
| Rate for Payer: Healthscope Commercial |
$226.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$214.20
|
| Rate for Payer: PHP Commercial |
$214.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.40
|
| Rate for Payer: Priority Health SBD |
$158.76
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$145.20
|
|
|
Service Code
|
NDC 6498033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.48 |
| Max. Negotiated Rate |
$130.68 |
| Rate for Payer: Aetna Commercial |
$123.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.38
|
| Rate for Payer: Cash Price |
$116.16
|
| Rate for Payer: Cofinity Commercial |
$101.64
|
| Rate for Payer: Cofinity Commercial |
$124.87
|
| Rate for Payer: Healthscope Commercial |
$130.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$123.42
|
| Rate for Payer: PHP Commercial |
$123.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.64
|
| Rate for Payer: Priority Health SBD |
$91.48
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
NDC 5164578599
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.92 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Aetna Commercial |
$156.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.60
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cofinity Commercial |
$128.80
|
| Rate for Payer: Cofinity Commercial |
$158.24
|
| Rate for Payer: Healthscope Commercial |
$165.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$156.40
|
| Rate for Payer: PHP Commercial |
$156.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.80
|
| Rate for Payer: Priority Health SBD |
$115.92
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$393.60
|
|
|
Service Code
|
NDC 6025817101
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.97 |
| Max. Negotiated Rate |
$354.24 |
| Rate for Payer: Aetna Commercial |
$334.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$255.84
|
| Rate for Payer: Cash Price |
$314.88
|
| Rate for Payer: Cofinity Commercial |
$275.52
|
| Rate for Payer: Cofinity Commercial |
$338.50
|
| Rate for Payer: Healthscope Commercial |
$354.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$334.56
|
| Rate for Payer: PHP Commercial |
$334.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$275.52
|
| Rate for Payer: Priority Health SBD |
$247.97
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
NDC 63739-354-10
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.40 |
| Max. Negotiated Rate |
$266.40 |
| Rate for Payer: Aetna Commercial |
$251.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.40
|
| Rate for Payer: BCBS Complete |
$118.40
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Cofinity Commercial |
$207.20
|
| Rate for Payer: Cofinity Commercial |
$254.56
|
| Rate for Payer: Healthscope Commercial |
$266.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$251.60
|
| Rate for Payer: PHP Commercial |
$251.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.20
|
| Rate for Payer: Priority Health SBD |
$186.48
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
NDC 63739-354-10
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.48 |
| Max. Negotiated Rate |
$266.40 |
| Rate for Payer: Aetna Commercial |
$251.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.40
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Cofinity Commercial |
$207.20
|
| Rate for Payer: Cofinity Commercial |
$254.56
|
| Rate for Payer: Healthscope Commercial |
$266.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$251.60
|
| Rate for Payer: PHP Commercial |
$251.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.20
|
| Rate for Payer: Priority Health SBD |
$186.48
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$158.76
|
|
|
Service Code
|
NDC 1000673038
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.02 |
| Max. Negotiated Rate |
$142.88 |
| Rate for Payer: Aetna Commercial |
$134.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.19
|
| Rate for Payer: Cash Price |
$127.01
|
| Rate for Payer: Cofinity Commercial |
$111.13
|
| Rate for Payer: Cofinity Commercial |
$136.53
|
| Rate for Payer: Healthscope Commercial |
$142.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$134.95
|
| Rate for Payer: PHP Commercial |
$134.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.13
|
| Rate for Payer: Priority Health SBD |
$100.02
|
|
|
MAGNESIUM SULFATE 0.5 GRAM/ML (50 %) INJECTION (CODE)
|
Facility
|
IP
|
$26.50
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
163706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.70 |
| Max. Negotiated Rate |
$23.85 |
| Rate for Payer: Aetna Commercial |
$22.52
|
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.94
|
| Rate for Payer: Cash Price |
$21.20
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cofinity Commercial |
$22.79
|
| Rate for Payer: Cofinity Commercial |
$15.01
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$18.55
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Commercial |
$23.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.52
|
| Rate for Payer: PHP Commercial |
$22.52
|
| Rate for Payer: PHP Commercial |
$18.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.55
|
| Rate for Payer: Priority Health SBD |
$13.51
|
| Rate for Payer: Priority Health SBD |
$16.70
|
|
