|
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$13,568.47
|
|
|
Service Code
|
MS-DRG 072
|
| Min. Negotiated Rate |
$5,825.13 |
| Max. Negotiated Rate |
$13,568.47 |
| Rate for Payer: Aetna Medicare |
$6,376.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,664.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,664.65
|
| Rate for Payer: BCBS MAPPO |
$6,131.72
|
| Rate for Payer: BCBS Trust/PPO |
$13,568.47
|
| Rate for Payer: BCN Medicare Advantage |
$6,131.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,131.72
|
| Rate for Payer: Mclaren Medicare |
$6,131.72
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,438.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,051.48
|
| Rate for Payer: PACE Medicare |
$5,825.13
|
| Rate for Payer: PACE SWMI |
$6,131.72
|
| Rate for Payer: PHP Medicare Advantage |
$6,131.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,235.99
|
| Rate for Payer: Priority Health Medicare |
$6,131.72
|
| Rate for Payer: Priority Health Narrow Network |
$8,988.79
|
| Rate for Payer: Railroad Medicare Medicare |
$6,131.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,943.88
|
| Rate for Payer: UHC Core |
$7,328.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,131.72
|
| Rate for Payer: UHC Exchange |
$7,849.58
|
| Rate for Payer: UHC Medicare Advantage |
$6,315.67
|
| Rate for Payer: VA VA |
$6,131.72
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC
|
Facility
|
IP
|
$26,890.99
|
|
|
Service Code
|
MS-DRG 067
|
| Min. Negotiated Rate |
$10,162.10 |
| Max. Negotiated Rate |
$26,890.99 |
| Rate for Payer: Aetna Medicare |
$11,124.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,371.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,371.19
|
| Rate for Payer: BCBS MAPPO |
$10,696.95
|
| Rate for Payer: BCBS Trust/PPO |
$26,890.99
|
| Rate for Payer: BCN Medicare Advantage |
$10,696.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,696.95
|
| Rate for Payer: Mclaren Medicare |
$10,696.95
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,231.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,301.49
|
| Rate for Payer: PACE Medicare |
$10,162.10
|
| Rate for Payer: PACE SWMI |
$10,696.95
|
| Rate for Payer: PHP Medicare Advantage |
$10,696.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,332.40
|
| Rate for Payer: Priority Health Medicare |
$10,696.95
|
| Rate for Payer: Priority Health Narrow Network |
$16,265.92
|
| Rate for Payer: Railroad Medicare Medicare |
$10,696.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21,613.39
|
| Rate for Payer: UHC Core |
$13,262.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,696.95
|
| Rate for Payer: UHC Exchange |
$14,204.42
|
| Rate for Payer: UHC Medicare Advantage |
$11,017.86
|
| Rate for Payer: VA VA |
$10,696.95
|
|
|
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC
|
Facility
|
IP
|
$15,981.76
|
|
|
Service Code
|
MS-DRG 068
|
| Min. Negotiated Rate |
$6,427.21 |
| Max. Negotiated Rate |
$15,981.76 |
| Rate for Payer: Aetna Medicare |
$7,036.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,456.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,456.85
|
| Rate for Payer: BCBS MAPPO |
$6,765.48
|
| Rate for Payer: BCBS Trust/PPO |
$15,981.76
|
| Rate for Payer: BCN Medicare Advantage |
$6,765.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,765.48
|
| Rate for Payer: Mclaren Medicare |
$6,765.48
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,103.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,780.30
|
| Rate for Payer: PACE Medicare |
$6,427.21
|
| Rate for Payer: PACE SWMI |
$6,765.48
|
| Rate for Payer: PHP Medicare Advantage |
$6,765.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,498.78
|
| Rate for Payer: Priority Health Medicare |
$6,765.48
|
| Rate for Payer: Priority Health Narrow Network |
$9,999.02
|
| Rate for Payer: Railroad Medicare Medicare |
$6,765.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,286.23
|
| Rate for Payer: UHC Core |
$8,152.56
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,765.48
|
| Rate for Payer: UHC Exchange |
$8,731.78
|
| Rate for Payer: UHC Medicare Advantage |
$6,968.44
|
| Rate for Payer: VA VA |
$6,765.48
|
|
|
NONTRAUMATIC STUPOR AND COMA WITH MCC
|
Facility
|
IP
|
$33,691.51
|
|
|
Service Code
|
MS-DRG 080
|
| Min. Negotiated Rate |
$15,579.35 |
| Max. Negotiated Rate |
$33,691.51 |
| Rate for Payer: Aetna Medicare |
$17,055.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,499.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,499.15
|
| Rate for Payer: BCBS MAPPO |
$16,399.32
|
| Rate for Payer: BCBS Trust/PPO |
$23,893.59
|
| Rate for Payer: BCN Medicare Advantage |
$16,399.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,399.32
|
| Rate for Payer: Mclaren Medicare |
$16,399.32
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,219.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18,859.22
|
| Rate for Payer: PACE Medicare |
$15,579.35
|
| Rate for Payer: PACE SWMI |
$16,399.32
|
| Rate for Payer: PHP Medicare Advantage |
$16,399.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31,694.67
|
| Rate for Payer: Priority Health Medicare |
$16,399.32
|
| Rate for Payer: Priority Health Narrow Network |
$25,355.74
|
| Rate for Payer: Railroad Medicare Medicare |
$16,399.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33,691.51
|
| Rate for Payer: UHC Core |
$20,673.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,399.32
|
| Rate for Payer: UHC Exchange |
$22,142.22
|
| Rate for Payer: UHC Medicare Advantage |
$16,891.30
|
| Rate for Payer: VA VA |
$16,399.32
|
|
|
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC
|
Facility
|
IP
|
$20,026.61
|
|
|
Service Code
|
MS-DRG 081
|
| Min. Negotiated Rate |
$6,690.63 |
| Max. Negotiated Rate |
$20,026.61 |
| Rate for Payer: Aetna Medicare |
$7,324.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,803.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,803.46
|
| Rate for Payer: BCBS MAPPO |
$7,042.77
|
| Rate for Payer: BCBS Trust/PPO |
$20,026.61
|
| Rate for Payer: BCN Medicare Advantage |
$7,042.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,042.77
|
| Rate for Payer: Mclaren Medicare |
$7,042.77
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,394.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,099.19
|
| Rate for Payer: PACE Medicare |
$6,690.63
|
| Rate for Payer: PACE SWMI |
$7,042.77
|
| Rate for Payer: PHP Medicare Advantage |
$7,042.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,051.25
|
| Rate for Payer: Priority Health Medicare |
$7,042.77
|
| Rate for Payer: Priority Health Narrow Network |
$10,441.00
|
| Rate for Payer: Railroad Medicare Medicare |
$7,042.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,873.51
|
| Rate for Payer: UHC Core |
$8,512.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$7,042.77
|
| Rate for Payer: UHC Exchange |
$9,117.74
|
| Rate for Payer: UHC Medicare Advantage |
$7,254.05
|
| Rate for Payer: VA VA |
$7,042.77
|
|
|
NOREPINEPHRINE 8 MG/250 ML (IV PREMIX)
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
NDC 9900-0003-69
|
| Hospital Charge Code |
161520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.42 |
| Max. Negotiated Rate |
$30.60 |
| Rate for Payer: Aetna Commercial |
$28.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.10
|
| Rate for Payer: Cash Price |
$27.20
|
| Rate for Payer: Cofinity Commercial |
$23.80
|
| Rate for Payer: Cofinity Commercial |
$29.24
|
| Rate for Payer: Healthscope Commercial |
$30.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.90
|
| Rate for Payer: PHP Commercial |
$28.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.80
|
| Rate for Payer: Priority Health SBD |
$21.42
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.46
|
|
|
Service Code
|
NDC 0143-9318-10
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.04 |
| Max. Negotiated Rate |
$22.91 |
| Rate for Payer: Aetna Commercial |
$21.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.55
|
| Rate for Payer: Cash Price |
$20.37
|
| Rate for Payer: Cofinity Commercial |
$17.82
|
| Rate for Payer: Cofinity Commercial |
$21.90
|
| Rate for Payer: Healthscope Commercial |
$22.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.64
|
| Rate for Payer: PHP Commercial |
$21.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.82
|
| Rate for Payer: Priority Health SBD |
$16.04
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$74.59
|
|
|
Service Code
|
NDC 0703-1153-03
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.99 |
| Max. Negotiated Rate |
$67.13 |
| Rate for Payer: Aetna Commercial |
$63.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.48
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: Cofinity Commercial |
$52.21
|
| Rate for Payer: Cofinity Commercial |
$64.15
|
| Rate for Payer: Healthscope Commercial |
$67.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.40
|
| Rate for Payer: PHP Commercial |
$63.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.21
|
| Rate for Payer: Priority Health SBD |
$46.99
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.36
|
|
|
Service Code
|
NDC 70121-1576-1
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$21.02 |
| Rate for Payer: Aetna Commercial |
$19.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.18
|
| Rate for Payer: Cash Price |
$18.69
|
| Rate for Payer: Cofinity Commercial |
$16.35
|
| Rate for Payer: Cofinity Commercial |
$20.09
|
| Rate for Payer: Healthscope Commercial |
$21.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.86
|
| Rate for Payer: PHP Commercial |
$19.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.35
|
| Rate for Payer: Priority Health SBD |
$14.72
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.36
|
|
|
Service Code
|
NDC 70121-1576-7
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$21.02 |
| Rate for Payer: Aetna Commercial |
$19.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.18
|
| Rate for Payer: Cash Price |
$18.69
|
| Rate for Payer: Cofinity Commercial |
$16.35
|
| Rate for Payer: Cofinity Commercial |
$20.09
|
| Rate for Payer: Healthscope Commercial |
$21.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.86
|
| Rate for Payer: PHP Commercial |
$19.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.35
|
| Rate for Payer: Priority Health SBD |
$14.72
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.37
|
|
|
Service Code
|
NDC 67457-852-00
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$16.53 |
| Rate for Payer: Aetna Commercial |
$15.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.94
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cofinity Commercial |
$12.86
|
| Rate for Payer: Cofinity Commercial |
$15.80
|
| Rate for Payer: Healthscope Commercial |
$16.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.61
|
| Rate for Payer: PHP Commercial |
$15.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.86
|
| Rate for Payer: Priority Health SBD |
$11.57
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.37
|
|
|
Service Code
|
NDC 67457-852-04
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$16.53 |
| Rate for Payer: Aetna Commercial |
$15.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.94
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cofinity Commercial |
$12.86
|
| Rate for Payer: Cofinity Commercial |
$15.80
|
| Rate for Payer: Healthscope Commercial |
$16.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.61
|
| Rate for Payer: PHP Commercial |
$15.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.86
|
| Rate for Payer: Priority Health SBD |
$11.57
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$107.05
|
|
|
Service Code
|
NDC 0409-3375-04
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.44 |
| Max. Negotiated Rate |
$96.34 |
| Rate for Payer: Aetna Commercial |
$90.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.58
|
| Rate for Payer: Cash Price |
$85.64
|
| Rate for Payer: Cofinity Commercial |
$74.94
|
| Rate for Payer: Cofinity Commercial |
$92.06
|
| Rate for Payer: Healthscope Commercial |
$96.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.99
|
| Rate for Payer: PHP Commercial |
$90.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.94
|
| Rate for Payer: Priority Health SBD |
$67.44
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$74.59
|
|
|
Service Code
|
NDC 0703-1153-01
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.99 |
| Max. Negotiated Rate |
$67.13 |
| Rate for Payer: Aetna Commercial |
$63.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.48
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: Cofinity Commercial |
$52.21
|
| Rate for Payer: Cofinity Commercial |
$64.15
|
| Rate for Payer: Healthscope Commercial |
$67.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.40
|
| Rate for Payer: PHP Commercial |
$63.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.21
|
| Rate for Payer: Priority Health SBD |
$46.99
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$28.63
|
|
|
Service Code
|
NDC 43066-997-10
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.04 |
| Max. Negotiated Rate |
$25.77 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.61
|
| Rate for Payer: Cash Price |
$22.90
|
| Rate for Payer: Cofinity Commercial |
$20.04
|
| Rate for Payer: Cofinity Commercial |
$24.62
|
| Rate for Payer: Healthscope Commercial |
$25.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.34
|
| Rate for Payer: PHP Commercial |
$24.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.04
|
| Rate for Payer: Priority Health SBD |
$18.04
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$28.63
|
|
|
Service Code
|
NDC 43066-997-01
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.04 |
| Max. Negotiated Rate |
$25.77 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.61
|
| Rate for Payer: Cash Price |
$22.90
|
| Rate for Payer: Cofinity Commercial |
$20.04
|
| Rate for Payer: Cofinity Commercial |
$24.62
|
| Rate for Payer: Healthscope Commercial |
$25.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.34
|
| Rate for Payer: PHP Commercial |
$24.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.04
|
| Rate for Payer: Priority Health SBD |
$18.04
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.46
|
|
|
Service Code
|
NDC 0143-9318-01
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.04 |
| Max. Negotiated Rate |
$22.91 |
| Rate for Payer: Aetna Commercial |
$21.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.55
|
| Rate for Payer: Cash Price |
$20.37
|
| Rate for Payer: Cofinity Commercial |
$17.82
|
| Rate for Payer: Cofinity Commercial |
$21.90
|
| Rate for Payer: Healthscope Commercial |
$22.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.64
|
| Rate for Payer: PHP Commercial |
$21.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.82
|
| Rate for Payer: Priority Health SBD |
$16.04
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 36000-162-10
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.76 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna Commercial |
$17.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.16
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Healthscope Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.21
|
| Rate for Payer: PHP Commercial |
$17.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.18
|
| Rate for Payer: Priority Health SBD |
$12.76
|
|
|
NORMAL NEWBORN
|
Facility
|
IP
|
$3,076.73
|
|
|
Service Code
|
MS-DRG 795
|
| Min. Negotiated Rate |
$625.00 |
| Max. Negotiated Rate |
$3,076.73 |
| Rate for Payer: Aetna Medicare |
$2,023.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,431.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,431.68
|
| Rate for Payer: BCBS MAPPO |
$1,945.34
|
| Rate for Payer: BCBS Trust/PPO |
$2,402.31
|
| Rate for Payer: BCN Medicare Advantage |
$1,945.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,945.34
|
| Rate for Payer: Mclaren Medicare |
$1,945.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,042.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,237.14
|
| Rate for Payer: PACE Medicare |
$1,848.07
|
| Rate for Payer: PACE SWMI |
$1,945.34
|
| Rate for Payer: PHP Medicare Advantage |
$1,945.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,894.38
|
| Rate for Payer: Priority Health Medicare |
$1,945.34
|
| Rate for Payer: Priority Health Narrow Network |
$2,315.50
|
| Rate for Payer: Railroad Medicare Medicare |
$1,945.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,076.73
|
| Rate for Payer: UHC Core |
$625.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,945.34
|
| Rate for Payer: UHC Medicare Advantage |
$2,003.70
|
| Rate for Payer: VA VA |
$1,945.34
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
OP
|
$132.05
|
|
|
Service Code
|
NDC 50268-603-15
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.82 |
| Max. Negotiated Rate |
$118.84 |
| Rate for Payer: Aetna Commercial |
$112.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.83
|
| Rate for Payer: BCBS Complete |
$52.82
|
| Rate for Payer: Cash Price |
$105.64
|
| Rate for Payer: Cofinity Commercial |
$113.56
|
| Rate for Payer: Cofinity Commercial |
$92.44
|
| Rate for Payer: Healthscope Commercial |
$118.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.24
|
| Rate for Payer: PHP Commercial |
$112.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.44
|
| Rate for Payer: Priority Health SBD |
$83.19
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
OP
|
$2.65
|
|
|
Service Code
|
NDC 50268-603-11
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.72
|
| Rate for Payer: BCBS Complete |
$1.06
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cofinity Commercial |
$1.86
|
| Rate for Payer: Cofinity Commercial |
$2.28
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.25
|
| Rate for Payer: PHP Commercial |
$2.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.86
|
| Rate for Payer: Priority Health SBD |
$1.67
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$2.65
|
|
|
Service Code
|
NDC 50268-603-11
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.72
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cofinity Commercial |
$1.86
|
| Rate for Payer: Cofinity Commercial |
$2.28
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.25
|
| Rate for Payer: PHP Commercial |
$2.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.86
|
| Rate for Payer: Priority Health SBD |
$1.67
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$309.70
|
|
|
Service Code
|
NDC 60687-281-01
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.11 |
| Max. Negotiated Rate |
$278.73 |
| Rate for Payer: Aetna Commercial |
$263.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.30
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$216.79
|
| Rate for Payer: Cofinity Commercial |
$266.34
|
| Rate for Payer: Healthscope Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$263.24
|
| Rate for Payer: PHP Commercial |
$263.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.79
|
| Rate for Payer: Priority Health SBD |
$195.11
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 60687-281-11
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Aetna Commercial |
$2.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.02
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Healthscope Commercial |
$2.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.64
|
| Rate for Payer: PHP Commercial |
$2.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.17
|
| Rate for Payer: Priority Health SBD |
$1.95
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$434.75
|
|
|
Service Code
|
NDC 0093-0810-01
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.89 |
| Max. Negotiated Rate |
$391.28 |
| Rate for Payer: Aetna Commercial |
$369.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$282.59
|
| Rate for Payer: Cash Price |
$347.80
|
| Rate for Payer: Cofinity Commercial |
$304.32
|
| Rate for Payer: Cofinity Commercial |
$373.88
|
| Rate for Payer: Healthscope Commercial |
$391.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$369.54
|
| Rate for Payer: PHP Commercial |
$369.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$304.32
|
| Rate for Payer: Priority Health SBD |
$273.89
|
|
