|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$51,968.17
|
|
|
Service Code
|
MS-DRG 827
|
| Min. Negotiated Rate |
$16,321.68 |
| Max. Negotiated Rate |
$51,968.17 |
| Rate for Payer: Aetna Medicare |
$17,867.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,475.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,475.90
|
| Rate for Payer: BCBS MAPPO |
$17,180.72
|
| Rate for Payer: BCBS Trust/PPO |
$51,968.17
|
| Rate for Payer: BCN Medicare Advantage |
$17,180.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,180.72
|
| Rate for Payer: Mclaren Medicare |
$17,180.72
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$18,039.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,757.83
|
| Rate for Payer: PACE Medicare |
$16,321.68
|
| Rate for Payer: PACE SWMI |
$17,180.72
|
| Rate for Payer: PHP Medicare Advantage |
$17,180.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33,251.63
|
| Rate for Payer: Priority Health Medicare |
$17,180.72
|
| Rate for Payer: Priority Health Narrow Network |
$26,601.30
|
| Rate for Payer: Railroad Medicare Medicare |
$17,180.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35,346.57
|
| Rate for Payer: UHC Core |
$21,688.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$17,180.72
|
| Rate for Payer: UHC Exchange |
$23,229.93
|
| Rate for Payer: UHC Medicare Advantage |
$17,696.14
|
| Rate for Payer: VA VA |
$17,180.72
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$66,946.76
|
|
|
Service Code
|
MS-DRG 826
|
| Min. Negotiated Rate |
$32,129.44 |
| Max. Negotiated Rate |
$66,946.76 |
| Rate for Payer: Aetna Medicare |
$35,173.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42,275.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42,275.58
|
| Rate for Payer: BCBS MAPPO |
$33,820.46
|
| Rate for Payer: BCBS Trust/PPO |
$52,462.25
|
| Rate for Payer: BCN Medicare Advantage |
$33,820.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$33,820.46
|
| Rate for Payer: Mclaren Medicare |
$33,820.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$35,511.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$38,893.53
|
| Rate for Payer: PACE Medicare |
$32,129.44
|
| Rate for Payer: PACE SWMI |
$33,820.46
|
| Rate for Payer: PHP Medicare Advantage |
$33,820.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$62,978.93
|
| Rate for Payer: Priority Health Medicare |
$33,820.46
|
| Rate for Payer: Priority Health Narrow Network |
$50,383.14
|
| Rate for Payer: Railroad Medicare Medicare |
$33,820.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$66,946.76
|
| Rate for Payer: UHC Core |
$41,079.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$33,820.46
|
| Rate for Payer: UHC Exchange |
$43,997.72
|
| Rate for Payer: UHC Medicare Advantage |
$34,835.07
|
| Rate for Payer: VA VA |
$33,820.46
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$35,692.16
|
|
|
Service Code
|
MS-DRG 828
|
| Min. Negotiated Rate |
$11,691.22 |
| Max. Negotiated Rate |
$35,692.16 |
| Rate for Payer: Aetna Medicare |
$12,798.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,383.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,383.19
|
| Rate for Payer: BCBS MAPPO |
$12,306.55
|
| Rate for Payer: BCBS Trust/PPO |
$35,692.16
|
| Rate for Payer: BCN Medicare Advantage |
$12,306.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,306.55
|
| Rate for Payer: Mclaren Medicare |
$12,306.55
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,921.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,152.53
|
| Rate for Payer: PACE Medicare |
$11,691.22
|
| Rate for Payer: PACE SWMI |
$12,306.55
|
| Rate for Payer: PHP Medicare Advantage |
$12,306.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23,539.61
|
| Rate for Payer: Priority Health Medicare |
$12,306.55
|
| Rate for Payer: Priority Health Narrow Network |
$18,831.69
|
| Rate for Payer: Railroad Medicare Medicare |
$12,306.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25,022.66
|
| Rate for Payer: UHC Core |
$15,354.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,306.55
|
| Rate for Payer: UHC Exchange |
$16,445.01
|
| Rate for Payer: UHC Medicare Advantage |
$12,675.75
|
| Rate for Payer: VA VA |
$12,306.55
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$71,294.29
|
|
|
Service Code
|
MS-DRG 829
|
| Min. Negotiated Rate |
$22,045.44 |
| Max. Negotiated Rate |
$71,294.29 |
| Rate for Payer: Aetna Medicare |
$24,133.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29,007.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29,007.16
|
| Rate for Payer: BCBS MAPPO |
$23,205.73
|
| Rate for Payer: BCBS Trust/PPO |
$71,294.29
|
| Rate for Payer: BCN Medicare Advantage |
$23,205.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23,205.73
|
| Rate for Payer: Mclaren Medicare |
$23,205.73
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$24,366.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26,686.59
|
| Rate for Payer: PACE Medicare |
$22,045.44
|
| Rate for Payer: PACE SWMI |
$23,205.73
|
| Rate for Payer: PHP Medicare Advantage |
$23,205.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$45,256.78
|
| Rate for Payer: Priority Health Medicare |
$23,205.73
|
| Rate for Payer: Priority Health Narrow Network |
$36,205.42
|
| Rate for Payer: Railroad Medicare Medicare |
$23,205.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$48,108.07
|
| Rate for Payer: UHC Core |
$29,519.57
|
| Rate for Payer: UHC Dual Complete DSNP |
$23,205.73
|
| Rate for Payer: UHC Exchange |
$31,616.85
|
| Rate for Payer: UHC Medicare Advantage |
$23,901.90
|
| Rate for Payer: VA VA |
$23,205.73
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$24,119.62
|
|
|
Service Code
|
MS-DRG 830
|
| Min. Negotiated Rate |
$11,286.19 |
| Max. Negotiated Rate |
$24,119.62 |
| Rate for Payer: Aetna Medicare |
$12,355.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,850.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,850.25
|
| Rate for Payer: BCBS MAPPO |
$11,880.20
|
| Rate for Payer: BCBS Trust/PPO |
$19,534.73
|
| Rate for Payer: BCN Medicare Advantage |
$11,880.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,880.20
|
| Rate for Payer: Mclaren Medicare |
$11,880.20
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,474.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,662.23
|
| Rate for Payer: PACE Medicare |
$11,286.19
|
| Rate for Payer: PACE SWMI |
$11,880.20
|
| Rate for Payer: PHP Medicare Advantage |
$11,880.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,690.09
|
| Rate for Payer: Priority Health Medicare |
$11,880.20
|
| Rate for Payer: Priority Health Narrow Network |
$18,152.07
|
| Rate for Payer: Railroad Medicare Medicare |
$11,880.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,119.62
|
| Rate for Payer: UHC Core |
$14,800.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,880.20
|
| Rate for Payer: UHC Exchange |
$15,851.53
|
| Rate for Payer: UHC Medicare Advantage |
$12,236.61
|
| Rate for Payer: VA VA |
$11,880.20
|
|
|
MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 58145
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$563.86 |
| 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 |
$1,195.54
|
| 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) |
$620.25
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,781.81
|
| Rate for Payer: UHC Exchange |
$563.86
|
| Rate for Payer: UHC Medicare Advantage |
$2,865.26
|
| Rate for Payer: VA VA |
$2,781.81
|
|
|
MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 69420
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$70.62 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: Aetna Medicare |
$226.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$271.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$271.68
|
| Rate for Payer: BCBS Complete |
$124.84
|
| Rate for Payer: BCBS MAPPO |
$217.34
|
| Rate for Payer: BCBS Trust/PPO |
$70.62
|
| Rate for Payer: BCN Medicare Advantage |
$217.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$217.34
|
| Rate for Payer: Mclaren Medicaid |
$118.88
|
| Rate for Payer: Mclaren Medicare |
$217.34
|
| Rate for Payer: Meridian Medicaid |
$124.84
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$228.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$249.94
|
| Rate for Payer: PACE Medicare |
$206.47
|
| Rate for Payer: PACE SWMI |
$217.34
|
| Rate for Payer: PHP Medicare Advantage |
$217.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$118.88
|
| Rate for Payer: Priority Health Medicare |
$217.34
|
| Rate for Payer: Railroad Medicare Medicare |
$217.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$131.82
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$217.34
|
| Rate for Payer: UHC Exchange |
$119.84
|
| Rate for Payer: UHC Medicare Advantage |
$223.86
|
| Rate for Payer: VA VA |
$217.34
|
|
|
NADOLOL 20 MG TABLET
|
Facility
|
IP
|
$1,150.33
|
|
|
Service Code
|
NDC 51079-812-20
|
| Hospital Charge Code |
5330
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$724.71 |
| Max. Negotiated Rate |
$1,035.30 |
| Rate for Payer: Aetna Commercial |
$977.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$747.71
|
| Rate for Payer: Cash Price |
$920.26
|
| Rate for Payer: Cofinity Commercial |
$805.23
|
| Rate for Payer: Cofinity Commercial |
$989.28
|
| Rate for Payer: Healthscope Commercial |
$1,035.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$977.78
|
| Rate for Payer: PHP Commercial |
$977.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$805.23
|
| Rate for Payer: Priority Health SBD |
$724.71
|
|
|
NADOLOL 20 MG TABLET
|
Facility
|
IP
|
$243.65
|
|
|
Service Code
|
NDC 0904-7070-07
|
| Hospital Charge Code |
5330
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.50 |
| Max. Negotiated Rate |
$219.28 |
| Rate for Payer: Aetna Commercial |
$207.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.37
|
| Rate for Payer: Cash Price |
$194.92
|
| Rate for Payer: Cofinity Commercial |
$170.56
|
| Rate for Payer: Cofinity Commercial |
$209.54
|
| Rate for Payer: Healthscope Commercial |
$219.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.10
|
| Rate for Payer: PHP Commercial |
$207.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.56
|
| Rate for Payer: Priority Health SBD |
$153.50
|
|
|
NADOLOL 20 MG TABLET
|
Facility
|
IP
|
$687.84
|
|
|
Service Code
|
NDC 0378-0028-01
|
| Hospital Charge Code |
5330
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$433.34 |
| Max. Negotiated Rate |
$619.06 |
| Rate for Payer: Aetna Commercial |
$584.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$447.10
|
| Rate for Payer: Cash Price |
$550.27
|
| Rate for Payer: Cofinity Commercial |
$481.49
|
| Rate for Payer: Cofinity Commercial |
$591.54
|
| Rate for Payer: Healthscope Commercial |
$619.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$584.66
|
| Rate for Payer: PHP Commercial |
$584.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$481.49
|
| Rate for Payer: Priority Health SBD |
$433.34
|
|
|
NADOLOL 20 MG TABLET
|
Facility
|
IP
|
$11.51
|
|
|
Service Code
|
NDC 51079-812-01
|
| Hospital Charge Code |
5330
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.25 |
| Max. Negotiated Rate |
$10.36 |
| Rate for Payer: Aetna Commercial |
$9.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.48
|
| Rate for Payer: Cash Price |
$9.21
|
| Rate for Payer: Cofinity Commercial |
$8.06
|
| Rate for Payer: Cofinity Commercial |
$9.90
|
| Rate for Payer: Healthscope Commercial |
$10.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.78
|
| Rate for Payer: PHP Commercial |
$9.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.06
|
| Rate for Payer: Priority Health SBD |
$7.25
|
|
|
NADOLOL 20 MG TABLET
|
Facility
|
IP
|
$376.00
|
|
|
Service Code
|
NDC 69097-867-07
|
| Hospital Charge Code |
5330
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$236.88 |
| Max. Negotiated Rate |
$338.40 |
| Rate for Payer: Aetna Commercial |
$319.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$244.40
|
| Rate for Payer: Cash Price |
$300.80
|
| Rate for Payer: Cofinity Commercial |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$323.36
|
| Rate for Payer: Healthscope Commercial |
$338.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$319.60
|
| Rate for Payer: PHP Commercial |
$319.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.20
|
| Rate for Payer: Priority Health SBD |
$236.88
|
|
|
NAFCILLIN 10 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$221.70
|
|
|
Service Code
|
NDC 0781-3126-95
|
| Hospital Charge Code |
5334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.67 |
| Max. Negotiated Rate |
$199.53 |
| Rate for Payer: Aetna Commercial |
$188.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.10
|
| Rate for Payer: Cash Price |
$177.36
|
| Rate for Payer: Cofinity Commercial |
$155.19
|
| Rate for Payer: Cofinity Commercial |
$190.66
|
| Rate for Payer: Healthscope Commercial |
$199.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$188.44
|
| Rate for Payer: PHP Commercial |
$188.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.19
|
| Rate for Payer: Priority Health SBD |
$139.67
|
|
|
NAFCILLIN 10 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$147.74
|
|
|
Service Code
|
NDC 55150-124-09
|
| Hospital Charge Code |
5334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.08 |
| Max. Negotiated Rate |
$132.97 |
| Rate for Payer: Aetna Commercial |
$125.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.03
|
| Rate for Payer: Cash Price |
$118.19
|
| Rate for Payer: Cofinity Commercial |
$103.42
|
| Rate for Payer: Cofinity Commercial |
$127.06
|
| Rate for Payer: Healthscope Commercial |
$132.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.58
|
| Rate for Payer: PHP Commercial |
$125.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.42
|
| Rate for Payer: Priority Health SBD |
$93.08
|
|
|
NAFCILLIN 10 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$147.74
|
|
|
Service Code
|
NDC 55150-124-99
|
| Hospital Charge Code |
5334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.08 |
| Max. Negotiated Rate |
$132.97 |
| Rate for Payer: Aetna Commercial |
$125.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.03
|
| Rate for Payer: Cash Price |
$118.19
|
| Rate for Payer: Cofinity Commercial |
$103.42
|
| Rate for Payer: Cofinity Commercial |
$127.06
|
| Rate for Payer: Healthscope Commercial |
$132.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.58
|
| Rate for Payer: PHP Commercial |
$125.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.42
|
| Rate for Payer: Priority Health SBD |
$93.08
|
|
|
NAFCILLIN 10 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$140.49
|
|
|
Service Code
|
NDC 70860-119-99
|
| Hospital Charge Code |
5334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.51 |
| Max. Negotiated Rate |
$126.44 |
| Rate for Payer: Aetna Commercial |
$119.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.32
|
| Rate for Payer: Cash Price |
$112.39
|
| Rate for Payer: Cofinity Commercial |
$98.34
|
| Rate for Payer: Cofinity Commercial |
$120.82
|
| Rate for Payer: Healthscope Commercial |
$126.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.42
|
| Rate for Payer: PHP Commercial |
$119.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.34
|
| Rate for Payer: Priority Health SBD |
$88.51
|
|
|
NAFCILLIN 1 GRAM IVPB (INTRA-OP)
|
Facility
|
IP
|
$5.70
|
|
|
Service Code
|
NDC 9900-0005-60
|
| Hospital Charge Code |
168910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.70
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cofinity Commercial |
$3.99
|
| Rate for Payer: Cofinity Commercial |
$4.90
|
| Rate for Payer: Healthscope Commercial |
$5.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.84
|
| Rate for Payer: PHP Commercial |
$4.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.99
|
| Rate for Payer: Priority Health SBD |
$3.59
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$25.63
|
|
|
Service Code
|
NDC 0409-3713-01
|
| Hospital Charge Code |
5333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$23.07 |
| Rate for Payer: Aetna Commercial |
$21.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.66
|
| Rate for Payer: Cash Price |
$20.50
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Cofinity Commercial |
$22.04
|
| Rate for Payer: Healthscope Commercial |
$23.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.79
|
| Rate for Payer: PHP Commercial |
$21.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.94
|
| Rate for Payer: Priority Health SBD |
$16.15
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$21.34
|
|
|
Service Code
|
NDC 44567-221-10
|
| Hospital Charge Code |
5333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$19.21 |
| Rate for Payer: Aetna Commercial |
$18.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.87
|
| Rate for Payer: Cash Price |
$17.07
|
| Rate for Payer: Cofinity Commercial |
$14.94
|
| Rate for Payer: Cofinity Commercial |
$18.35
|
| Rate for Payer: Healthscope Commercial |
$19.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.14
|
| Rate for Payer: PHP Commercial |
$18.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.94
|
| Rate for Payer: Priority Health SBD |
$13.44
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$20.88
|
|
|
Service Code
|
NDC 55150-122-15
|
| Hospital Charge Code |
5333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.15 |
| Max. Negotiated Rate |
$18.79 |
| Rate for Payer: Aetna Commercial |
$17.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.57
|
| Rate for Payer: Cash Price |
$16.70
|
| Rate for Payer: Cofinity Commercial |
$14.62
|
| Rate for Payer: Cofinity Commercial |
$17.96
|
| Rate for Payer: Healthscope Commercial |
$18.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.75
|
| Rate for Payer: PHP Commercial |
$17.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.62
|
| Rate for Payer: Priority Health SBD |
$13.15
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$47.88
|
|
|
Service Code
|
NDC 0781-9124-85
|
| Hospital Charge Code |
5333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.16 |
| Max. Negotiated Rate |
$43.09 |
| Rate for Payer: Aetna Commercial |
$40.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.12
|
| Rate for Payer: Cash Price |
$38.30
|
| Rate for Payer: Cofinity Commercial |
$33.52
|
| Rate for Payer: Cofinity Commercial |
$41.18
|
| Rate for Payer: Healthscope Commercial |
$43.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$40.70
|
| Rate for Payer: PHP Commercial |
$40.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.52
|
| Rate for Payer: Priority Health SBD |
$30.16
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$61.54
|
|
|
Service Code
|
NDC 63323-327-10
|
| Hospital Charge Code |
5333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.77 |
| Max. Negotiated Rate |
$55.39 |
| Rate for Payer: Aetna Commercial |
$52.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.00
|
| Rate for Payer: Cash Price |
$49.23
|
| Rate for Payer: Cofinity Commercial |
$43.08
|
| Rate for Payer: Cofinity Commercial |
$52.92
|
| Rate for Payer: Healthscope Commercial |
$55.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.31
|
| Rate for Payer: PHP Commercial |
$52.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.08
|
| Rate for Payer: Priority Health SBD |
$38.77
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$25.63
|
|
|
Service Code
|
NDC 0409-3713-10
|
| Hospital Charge Code |
5333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$23.07 |
| Rate for Payer: Aetna Commercial |
$21.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.66
|
| Rate for Payer: Cash Price |
$20.50
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Cofinity Commercial |
$22.04
|
| Rate for Payer: Healthscope Commercial |
$23.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.79
|
| Rate for Payer: PHP Commercial |
$21.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.94
|
| Rate for Payer: Priority Health SBD |
$16.15
|
|
|
NAFCILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$47.88
|
|
|
Service Code
|
NDC 0781-3124-95
|
| Hospital Charge Code |
5333
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.16 |
| Max. Negotiated Rate |
$43.09 |
| Rate for Payer: Aetna Commercial |
$40.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.12
|
| Rate for Payer: Cash Price |
$38.30
|
| Rate for Payer: Cofinity Commercial |
$33.52
|
| Rate for Payer: Cofinity Commercial |
$41.18
|
| Rate for Payer: Healthscope Commercial |
$43.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$40.70
|
| Rate for Payer: PHP Commercial |
$40.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.52
|
| Rate for Payer: Priority Health SBD |
$30.16
|
|
|
NAFCILLIN 2 GRAM IVPB (INTRA-OP)
|
Facility
|
IP
|
$21.20
|
|
|
Service Code
|
NDC 9900-0005-61
|
| Hospital Charge Code |
168911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.36 |
| Max. Negotiated Rate |
$19.08 |
| Rate for Payer: Aetna Commercial |
$18.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.78
|
| Rate for Payer: Cash Price |
$16.96
|
| Rate for Payer: Cofinity Commercial |
$14.84
|
| Rate for Payer: Cofinity Commercial |
$18.23
|
| Rate for Payer: Healthscope Commercial |
$19.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.02
|
| Rate for Payer: PHP Commercial |
$18.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.84
|
| Rate for Payer: Priority Health SBD |
$13.36
|
|
