|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0085-04
|
| Hospital Charge Code |
9814
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.97 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0085-04
|
| Hospital Charge Code |
9814
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$67.19
|
|
|
Service Code
|
NDC 0338-0085-03
|
| Hospital Charge Code |
9814
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.88 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health SBD |
$42.33
|
|
|
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 1.5X MAINTENANCE
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0089-04
|
| Hospital Charge Code |
300210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$87.73
|
|
|
Service Code
|
NDC 0338-0089-03
|
| Hospital Charge Code |
9815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.27 |
| Max. Negotiated Rate |
$78.96 |
| Rate for Payer: Aetna Commercial |
$74.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.02
|
| Rate for Payer: Cash Price |
$70.18
|
| Rate for Payer: Cofinity Commercial |
$61.41
|
| Rate for Payer: Cofinity Commercial |
$75.45
|
| Rate for Payer: Healthscope Commercial |
$78.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.57
|
| Rate for Payer: PHP Commercial |
$74.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.41
|
| Rate for Payer: Priority Health SBD |
$55.27
|
|
|
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0089-04
|
| Hospital Charge Code |
9815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0089-04
|
| Hospital Charge Code |
9815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.97 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
9788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5% IN WATER (D5W) FLUSH
|
Facility
|
IP
|
$59.35
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
161492
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.39 |
| Max. Negotiated Rate |
$53.42 |
| Rate for Payer: Aetna Commercial |
$50.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.58
|
| Rate for Payer: Cash Price |
$47.48
|
| Rate for Payer: Cofinity Commercial |
$41.54
|
| Rate for Payer: Cofinity Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$53.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.45
|
| Rate for Payer: PHP Commercial |
$50.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.54
|
| Rate for Payer: Priority Health SBD |
$37.39
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$172.75
|
|
|
Service Code
|
NDC 0338-9147-30
|
| Hospital Charge Code |
116171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.83 |
| Max. Negotiated Rate |
$155.48 |
| Rate for Payer: Aetna Commercial |
$146.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.29
|
| Rate for Payer: Cash Price |
$138.20
|
| Rate for Payer: Cofinity Commercial |
$120.92
|
| Rate for Payer: Cofinity Commercial |
$148.56
|
| Rate for Payer: Healthscope Commercial |
$155.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$146.84
|
| Rate for Payer: PHP Commercial |
$146.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.92
|
| Rate for Payer: Priority Health SBD |
$108.83
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$55.99
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.27 |
| Max. Negotiated Rate |
$50.39 |
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health SBD |
$36.68
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: Priority Health SBD |
$42.33
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$67.19
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$5.70
|
| Rate for Payer: BCBS Trust/PPO |
$5.70
|
| Rate for Payer: BCBS Trust/PPO |
$5.70
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.59
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.19
|
| Rate for Payer: Priority Health SBD |
$36.68
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: Priority Health SBD |
$42.33
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.42 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$11.42
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV ADDITIONAL SOLUTION
|
Facility
|
IP
|
$58.23
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
180629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.68 |
| Max. Negotiated Rate |
$52.41 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.50
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5% IN WATER INTRAVENOUS SOLUTION (DOSE, ADMIN OVER & INDICATION REQUIRED)
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
301087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.42 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$11.42
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5% IN WATER INTRAVENOUS SOLUTION (DOSE, ADMIN OVER & INDICATION REQUIRED)
|
Facility
|
OP
|
$55.99
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
301087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$50.39 |
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: BCBS Trust/PPO |
$5.70
|
| Rate for Payer: BCBS Trust/PPO |
$5.70
|
| Rate for Payer: BCBS Trust/PPO |
$5.70
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.50
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.19
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$67.19
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.59
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.19
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$35.27
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$110.16
|
|
|
Service Code
|
NDC 0338-0719-06
|
| Hospital Charge Code |
2367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.40 |
| Max. Negotiated Rate |
$99.14 |
| Rate for Payer: Aetna Commercial |
$93.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.60
|
| Rate for Payer: Cash Price |
$88.13
|
| Rate for Payer: Cofinity Commercial |
$77.11
|
| Rate for Payer: Cofinity Commercial |
$94.74
|
| Rate for Payer: Healthscope Commercial |
$99.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.64
|
| Rate for Payer: PHP Commercial |
$93.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.11
|
| Rate for Payer: Priority Health SBD |
$69.40
|
|
|
DIABETES WITH CC
|
Facility
|
IP
|
$13,719.45
|
|
|
Service Code
|
MS-DRG 638
|
| Min. Negotiated Rate |
$6,621.51 |
| Max. Negotiated Rate |
$13,719.45 |
| Rate for Payer: Aetna Medicare |
$7,248.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,712.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,712.51
|
| Rate for Payer: BCBS MAPPO |
$6,970.01
|
| Rate for Payer: BCBS Trust/PPO |
$11,477.97
|
| Rate for Payer: BCN Medicare Advantage |
$6,970.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,970.01
|
| Rate for Payer: Mclaren Medicare |
$6,970.01
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,318.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,015.51
|
| Rate for Payer: PACE Medicare |
$6,621.51
|
| Rate for Payer: PACE SWMI |
$6,970.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,970.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,906.32
|
| Rate for Payer: Priority Health Medicare |
$6,970.01
|
| Rate for Payer: Priority Health Narrow Network |
$10,325.06
|
| Rate for Payer: Railroad Medicare Medicare |
$6,970.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,719.45
|
| Rate for Payer: UHC Core |
$8,418.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,970.01
|
| Rate for Payer: UHC Exchange |
$9,016.49
|
| Rate for Payer: UHC Medicare Advantage |
$7,179.11
|
| Rate for Payer: VA VA |
$6,970.01
|
|
|
DIABETES WITH MCC
|
Facility
|
IP
|
$22,107.62
|
|
|
Service Code
|
MS-DRG 637
|
| Min. Negotiated Rate |
$10,383.77 |
| Max. Negotiated Rate |
$22,107.62 |
| Rate for Payer: Aetna Medicare |
$11,367.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,662.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,662.85
|
| Rate for Payer: BCBS MAPPO |
$10,930.28
|
| Rate for Payer: BCBS Trust/PPO |
$18,256.71
|
| Rate for Payer: BCN Medicare Advantage |
$10,930.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,930.28
|
| Rate for Payer: Mclaren Medicare |
$10,930.28
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,476.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,569.82
|
| Rate for Payer: PACE Medicare |
$10,383.77
|
| Rate for Payer: PACE SWMI |
$10,930.28
|
| Rate for Payer: PHP Medicare Advantage |
$10,930.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,797.34
|
| Rate for Payer: Priority Health Medicare |
$10,930.28
|
| Rate for Payer: Priority Health Narrow Network |
$16,637.87
|
| Rate for Payer: Railroad Medicare Medicare |
$10,930.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22,107.62
|
| Rate for Payer: UHC Core |
$13,565.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,930.28
|
| Rate for Payer: UHC Exchange |
$14,529.23
|
| Rate for Payer: UHC Medicare Advantage |
$11,258.19
|
| Rate for Payer: VA VA |
$10,930.28
|
|
|
DIABETES WITHOUT CC/MCC
|
Facility
|
IP
|
$9,495.62
|
|
|
Service Code
|
MS-DRG 639
|
| Min. Negotiated Rate |
$4,727.06 |
| Max. Negotiated Rate |
$9,495.62 |
| Rate for Payer: Aetna Medicare |
$5,174.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,219.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,219.81
|
| Rate for Payer: BCBS MAPPO |
$4,975.85
|
| Rate for Payer: BCBS Trust/PPO |
$9,286.46
|
| Rate for Payer: BCN Medicare Advantage |
$4,975.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,975.85
|
| Rate for Payer: Mclaren Medicare |
$4,975.85
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,224.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,722.23
|
| Rate for Payer: PACE Medicare |
$4,727.06
|
| Rate for Payer: PACE SWMI |
$4,975.85
|
| Rate for Payer: PHP Medicare Advantage |
$4,975.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,932.83
|
| Rate for Payer: Priority Health Medicare |
$4,975.85
|
| Rate for Payer: Priority Health Narrow Network |
$7,146.26
|
| Rate for Payer: Railroad Medicare Medicare |
$4,975.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,495.62
|
| Rate for Payer: UHC Core |
$5,826.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,975.85
|
| Rate for Payer: UHC Exchange |
$6,240.56
|
| Rate for Payer: UHC Medicare Advantage |
$5,125.13
|
| Rate for Payer: VA VA |
$4,975.85
|
|
|
DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.50
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cofinity Commercial |
$63.00
|
| Rate for Payer: Cofinity Commercial |
$77.40
|
| Rate for Payer: Healthscope Commercial |
$81.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$76.50
|
| Rate for Payer: PHP Commercial |
$76.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.00
|
| Rate for Payer: Priority Health SBD |
$56.70
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION
|
Facility
|
IP
|
$182.50
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
27735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.98 |
| Max. Negotiated Rate |
$164.25 |
| Rate for Payer: Aetna Commercial |
$155.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.62
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cofinity Commercial |
$127.75
|
| Rate for Payer: Cofinity Commercial |
$156.95
|
| Rate for Payer: Healthscope Commercial |
$164.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$155.12
|
| Rate for Payer: PHP Commercial |
$155.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$127.75
|
| Rate for Payer: Priority Health SBD |
$114.98
|
|
