|
PNEUMOTHORAX WITH CC
|
Facility
|
IP
|
$17,918.59
|
|
|
Service Code
|
MSDRG 200
|
| Min. Negotiated Rate |
$8,620.92 |
| Max. Negotiated Rate |
$17,918.59 |
| Rate for Payer: Aetna Medicare |
$9,437.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,343.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,343.31
|
| Rate for Payer: BCBS MAPPO |
$9,074.65
|
| Rate for Payer: BCBS Trust/PPO |
$16,334.10
|
| Rate for Payer: BCN Commercial |
$16,334.10
|
| Rate for Payer: BCN Medicare Advantage |
$9,074.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,074.65
|
| Rate for Payer: Mclaren Medicare |
$9,074.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9,528.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,435.85
|
| Rate for Payer: Molina Medicare/Medicaid |
$9,982.11
|
| Rate for Payer: Nomi Health Commercial |
$14,180.97
|
| Rate for Payer: PACE Medicare |
$8,620.92
|
| Rate for Payer: PACE SWMI |
$9,074.65
|
| Rate for Payer: PHP Medicare Advantage |
$9,074.65
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$17,723.07
|
| Rate for Payer: Priority Health Medicare |
$9,074.65
|
| Rate for Payer: Priority Health Tiered Network |
$14,178.45
|
| Rate for Payer: Railroad Medicare Medicare |
$9,074.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,918.59
|
| Rate for Payer: UHC Core |
$14,991.15
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9,074.65
|
| Rate for Payer: UHC Exchange |
$12,242.90
|
| Rate for Payer: VA VA |
$9,074.65
|
|
|
PNEUMOTHORAX WITH MCC
|
Facility
|
IP
|
$28,754.83
|
|
|
Service Code
|
MSDRG 199
|
| Min. Negotiated Rate |
$13,501.74 |
| Max. Negotiated Rate |
$28,754.83 |
| Rate for Payer: Aetna Medicare |
$14,780.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,765.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,765.45
|
| Rate for Payer: BCBS MAPPO |
$14,212.36
|
| Rate for Payer: BCBS Trust/PPO |
$22,602.76
|
| Rate for Payer: BCN Commercial |
$22,602.76
|
| Rate for Payer: BCN Medicare Advantage |
$14,212.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,212.36
|
| Rate for Payer: Mclaren Medicare |
$14,212.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14,922.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,344.21
|
| Rate for Payer: Molina Medicare/Medicaid |
$15,633.60
|
| Rate for Payer: Nomi Health Commercial |
$22,756.89
|
| Rate for Payer: PACE Medicare |
$13,501.74
|
| Rate for Payer: PACE SWMI |
$14,212.36
|
| Rate for Payer: PHP Medicare Advantage |
$14,212.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$28,441.07
|
| Rate for Payer: Priority Health Medicare |
$14,212.36
|
| Rate for Payer: Priority Health Tiered Network |
$22,752.85
|
| Rate for Payer: Railroad Medicare Medicare |
$14,212.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28,754.83
|
| Rate for Payer: UHC Core |
$24,057.03
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$14,212.36
|
| Rate for Payer: UHC Exchange |
$19,646.78
|
| Rate for Payer: VA VA |
$14,212.36
|
|
|
PNEUMOTHORAX WITHOUT CC/MCC
|
Facility
|
IP
|
$11,656.13
|
|
|
Service Code
|
MSDRG 201
|
| Min. Negotiated Rate |
$5,800.17 |
| Max. Negotiated Rate |
$11,656.13 |
| Rate for Payer: Aetna Medicare |
$6,349.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,631.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,631.80
|
| Rate for Payer: BCBS MAPPO |
$6,105.44
|
| Rate for Payer: BCBS Trust/PPO |
$11,111.78
|
| Rate for Payer: BCN Commercial |
$11,111.78
|
| Rate for Payer: BCN Medicare Advantage |
$6,105.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,105.44
|
| Rate for Payer: Mclaren Medicare |
$6,105.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,410.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,021.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$6,715.98
|
| Rate for Payer: Nomi Health Commercial |
$9,224.79
|
| Rate for Payer: PACE Medicare |
$5,800.17
|
| Rate for Payer: PACE SWMI |
$6,105.44
|
| Rate for Payer: PHP Medicare Advantage |
$6,105.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$11,528.94
|
| Rate for Payer: Priority Health Medicare |
$6,105.44
|
| Rate for Payer: Priority Health Tiered Network |
$9,223.15
|
| Rate for Payer: Railroad Medicare Medicare |
$6,105.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,656.13
|
| Rate for Payer: UHC Core |
$9,751.82
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,105.44
|
| Rate for Payer: UHC Exchange |
$7,964.07
|
| Rate for Payer: VA VA |
$6,105.44
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC
|
Facility
|
IP
|
$25,564.92
|
|
|
Service Code
|
MSDRG 917
|
| Min. Negotiated Rate |
$12,064.94 |
| Max. Negotiated Rate |
$25,564.92 |
| Rate for Payer: Aetna Medicare |
$13,207.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,874.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,874.92
|
| Rate for Payer: BCBS MAPPO |
$12,699.94
|
| Rate for Payer: BCBS Trust/PPO |
$24,353.68
|
| Rate for Payer: BCN Commercial |
$24,353.68
|
| Rate for Payer: BCN Medicare Advantage |
$12,699.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,699.94
|
| Rate for Payer: Mclaren Medicare |
$12,699.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,334.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,604.93
|
| Rate for Payer: Molina Medicare/Medicaid |
$13,969.93
|
| Rate for Payer: Nomi Health Commercial |
$20,232.36
|
| Rate for Payer: PACE Medicare |
$12,064.94
|
| Rate for Payer: PACE SWMI |
$12,699.94
|
| Rate for Payer: PHP Medicare Advantage |
$12,699.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$25,285.96
|
| Rate for Payer: Priority Health Medicare |
$12,699.94
|
| Rate for Payer: Priority Health Tiered Network |
$20,228.77
|
| Rate for Payer: Railroad Medicare Medicare |
$12,699.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25,564.92
|
| Rate for Payer: UHC Core |
$21,388.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12,699.94
|
| Rate for Payer: UHC Exchange |
$17,467.27
|
| Rate for Payer: VA VA |
$12,699.94
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC
|
Facility
|
IP
|
$13,970.73
|
|
|
Service Code
|
MSDRG 918
|
| Min. Negotiated Rate |
$6,842.73 |
| Max. Negotiated Rate |
$13,970.73 |
| Rate for Payer: Aetna Medicare |
$7,490.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,003.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,003.59
|
| Rate for Payer: BCBS MAPPO |
$7,202.87
|
| Rate for Payer: BCBS Trust/PPO |
$9,953.08
|
| Rate for Payer: BCN Commercial |
$9,953.08
|
| Rate for Payer: BCN Medicare Advantage |
$7,202.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,202.87
|
| Rate for Payer: Mclaren Medicare |
$7,202.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,563.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,283.30
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,923.16
|
| Rate for Payer: Nomi Health Commercial |
$11,056.59
|
| Rate for Payer: PACE Medicare |
$6,842.73
|
| Rate for Payer: PACE SWMI |
$7,202.87
|
| Rate for Payer: PHP Medicare Advantage |
$7,202.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$13,818.29
|
| Rate for Payer: Priority Health Medicare |
$7,202.87
|
| Rate for Payer: Priority Health Tiered Network |
$11,054.63
|
| Rate for Payer: Railroad Medicare Medicare |
$7,202.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,970.73
|
| Rate for Payer: UHC Core |
$11,688.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,202.87
|
| Rate for Payer: UHC Exchange |
$9,545.52
|
| Rate for Payer: VA VA |
$7,202.87
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$5,516.87
|
|
|
Service Code
|
APR-DRG 8123
|
| Min. Negotiated Rate |
$5,254.16 |
| Max. Negotiated Rate |
$5,516.87 |
| Rate for Payer: BCBS Complete |
$5,516.87
|
| Rate for Payer: Mclaren Medicaid |
$5,254.16
|
| Rate for Payer: Meridian Medicaid |
$5,516.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,254.16
|
| Rate for Payer: UHC Medicaid |
$5,254.16
|
| Rate for Payer: UHCCP Medicaid |
$5,254.16
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$3,911.63
|
|
|
Service Code
|
APR-DRG 8122
|
| Min. Negotiated Rate |
$3,725.36 |
| Max. Negotiated Rate |
$3,911.63 |
| Rate for Payer: BCBS Complete |
$3,911.63
|
| Rate for Payer: Mclaren Medicaid |
$3,725.36
|
| Rate for Payer: Meridian Medicaid |
$3,911.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,725.36
|
| Rate for Payer: UHC Medicaid |
$3,725.36
|
| Rate for Payer: UHCCP Medicaid |
$3,725.36
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$2,570.68
|
|
|
Service Code
|
APR-DRG 8121
|
| Min. Negotiated Rate |
$2,448.26 |
| Max. Negotiated Rate |
$2,570.68 |
| Rate for Payer: BCBS Complete |
$2,570.68
|
| Rate for Payer: Mclaren Medicaid |
$2,448.26
|
| Rate for Payer: Meridian Medicaid |
$2,570.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,448.26
|
| Rate for Payer: UHC Medicaid |
$2,448.26
|
| Rate for Payer: UHCCP Medicaid |
$2,448.26
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$10,779.19
|
|
|
Service Code
|
APR-DRG 8124
|
| Min. Negotiated Rate |
$10,265.89 |
| Max. Negotiated Rate |
$10,779.19 |
| Rate for Payer: BCBS Complete |
$10,779.19
|
| Rate for Payer: Mclaren Medicaid |
$10,265.89
|
| Rate for Payer: Meridian Medicaid |
$10,779.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,265.89
|
| Rate for Payer: UHC Medicaid |
$10,265.89
|
| Rate for Payer: UHCCP Medicaid |
$10,265.89
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18,981.30
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
195050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.77 |
| Max. Negotiated Rate |
$17,083.17 |
| Rate for Payer: Aetna Commercial |
$16,134.10
|
| Rate for Payer: Aetna Medicare |
$142.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,337.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$171.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$171.54
|
| Rate for Payer: BCBS Complete |
$75.37
|
| Rate for Payer: BCBS MAPPO |
$137.23
|
| Rate for Payer: BCBS Trust/PPO |
$343.14
|
| Rate for Payer: BCN Commercial |
$343.14
|
| Rate for Payer: BCN Medicare Advantage |
$137.23
|
| Rate for Payer: Cash Price |
$15,185.04
|
| Rate for Payer: Cash Price |
$15,185.04
|
| Rate for Payer: Cofinity Advantage |
$13,286.91
|
| Rate for Payer: Cofinity Commercial |
$16,323.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,185.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$137.23
|
| Rate for Payer: Healthscope Commercial |
$17,083.17
|
| Rate for Payer: Mclaren Medicaid |
$71.77
|
| Rate for Payer: Mclaren Medicare |
$137.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$144.09
|
| Rate for Payer: Meridian Medicaid |
$144.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$157.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$150.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,134.10
|
| Rate for Payer: Nomi Health Commercial |
$411.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,235.98
|
| Rate for Payer: PACE Medicare |
$130.37
|
| Rate for Payer: PACE SWMI |
$137.23
|
| Rate for Payer: PHP Commercial |
$16,134.10
|
| Rate for Payer: PHP Medicare Advantage |
$137.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$71.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$431.04
|
| Rate for Payer: Priority Health Medicare |
$137.23
|
| Rate for Payer: Priority Health SBD |
$11,958.22
|
| Rate for Payer: Priority Health Tiered Network |
$344.83
|
| Rate for Payer: Railroad Medicare Medicare |
$137.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$225.67
|
| Rate for Payer: UHC Core |
$225.67
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$137.23
|
| Rate for Payer: UHC Exchange |
$225.67
|
| Rate for Payer: UHC Medicaid |
$71.77
|
| Rate for Payer: UHCCP Medicaid |
$71.77
|
| Rate for Payer: VA VA |
$137.23
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$93.54
|
|
|
Service Code
|
NDC 67850014105
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.93 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Advantage |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.16
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health SBD |
$58.93
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$93.54
|
|
|
Service Code
|
NDC 67850014100
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna Medicare |
$46.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: BCBS Complete |
$37.42
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Advantage |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.16
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.80
|
| Rate for Payer: UHC Core |
$48.73
|
| Rate for Payer: UHC Exchange |
$36.76
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$93.54
|
|
|
Service Code
|
NDC 67850014100
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.93 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Advantage |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.16
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health SBD |
$58.93
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$93.54
|
|
|
Service Code
|
NDC 67850014105
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$84.19 |
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna Medicare |
$46.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.80
|
| Rate for Payer: BCBS Complete |
$37.42
|
| Rate for Payer: Cash Price |
$74.83
|
| Rate for Payer: Cofinity Advantage |
$65.48
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.83
|
| Rate for Payer: Healthscope Commercial |
$84.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.16
|
| Rate for Payer: PHP Commercial |
$79.51
|
| Rate for Payer: Priority Health SBD |
$58.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.80
|
| Rate for Payer: UHC Core |
$48.73
|
| Rate for Payer: UHC Exchange |
$36.76
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$16.61
|
|
|
Service Code
|
NDC 45802086801
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna Commercial |
$14.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.80
|
| Rate for Payer: Cash Price |
$13.29
|
| Rate for Payer: Cofinity Advantage |
$11.63
|
| Rate for Payer: Cofinity Commercial |
$14.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.29
|
| Rate for Payer: Healthscope Commercial |
$14.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.46
|
| Rate for Payer: PHP Commercial |
$14.12
|
| Rate for Payer: Priority Health SBD |
$10.46
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$11.25
|
|
|
Service Code
|
NDC 09629513543
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.56
|
| Rate for Payer: Aetna Medicare |
$5.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.31
|
| Rate for Payer: BCBS Complete |
$4.50
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cofinity Advantage |
$7.88
|
| Rate for Payer: Cofinity Commercial |
$9.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.00
|
| Rate for Payer: Healthscope Commercial |
$10.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.44
|
| Rate for Payer: PHP Commercial |
$9.56
|
| Rate for Payer: Priority Health SBD |
$7.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.31
|
| Rate for Payer: UHC Core |
$5.86
|
| Rate for Payer: UHC Exchange |
$4.42
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$16.61
|
|
|
Service Code
|
NDC 45802086801
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.53 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna Commercial |
$14.12
|
| Rate for Payer: Aetna Medicare |
$8.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.80
|
| Rate for Payer: BCBS Complete |
$6.64
|
| Rate for Payer: Cash Price |
$13.29
|
| Rate for Payer: Cofinity Advantage |
$11.63
|
| Rate for Payer: Cofinity Commercial |
$14.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.29
|
| Rate for Payer: Healthscope Commercial |
$14.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.46
|
| Rate for Payer: PHP Commercial |
$14.12
|
| Rate for Payer: Priority Health SBD |
$10.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.80
|
| Rate for Payer: UHC Core |
$8.65
|
| Rate for Payer: UHC Exchange |
$6.53
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
OP
|
$25.83
|
|
|
Service Code
|
NDC 41100082076
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna Medicare |
$12.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: BCBS Complete |
$10.33
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cofinity Advantage |
$18.08
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.66
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.37
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: Priority Health SBD |
$16.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.79
|
| Rate for Payer: UHC Core |
$13.46
|
| Rate for Payer: UHC Exchange |
$10.15
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$11.25
|
|
|
Service Code
|
NDC 09629513543
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.31
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cofinity Advantage |
$7.88
|
| Rate for Payer: Cofinity Commercial |
$9.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.00
|
| Rate for Payer: Healthscope Commercial |
$10.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.44
|
| Rate for Payer: PHP Commercial |
$9.56
|
| Rate for Payer: Priority Health SBD |
$7.09
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$25.83
|
|
|
Service Code
|
NDC 41100082076
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.27 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cofinity Advantage |
$18.08
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.66
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.37
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: Priority Health SBD |
$16.27
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$192.39
|
|
|
Service Code
|
NDC 51079030630
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.61 |
| Max. Negotiated Rate |
$173.15 |
| Rate for Payer: Aetna Commercial |
$163.53
|
| Rate for Payer: Aetna Medicare |
$96.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.05
|
| Rate for Payer: BCBS Complete |
$76.96
|
| Rate for Payer: Cash Price |
$153.91
|
| Rate for Payer: Cofinity Advantage |
$134.67
|
| Rate for Payer: Cofinity Commercial |
$165.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.91
|
| Rate for Payer: Healthscope Commercial |
$173.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$153.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$144.29
|
| Rate for Payer: PHP Commercial |
$163.53
|
| Rate for Payer: Priority Health SBD |
$121.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$125.05
|
| Rate for Payer: UHC Core |
$100.24
|
| Rate for Payer: UHC Exchange |
$75.61
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$98.18
|
|
|
Service Code
|
NDC 45802086866
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$88.36 |
| Rate for Payer: Aetna Commercial |
$83.45
|
| Rate for Payer: Aetna Medicare |
$49.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.82
|
| Rate for Payer: BCBS Complete |
$39.27
|
| Rate for Payer: Cash Price |
$78.54
|
| Rate for Payer: Cofinity Advantage |
$68.73
|
| Rate for Payer: Cofinity Commercial |
$84.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.54
|
| Rate for Payer: Healthscope Commercial |
$88.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$73.64
|
| Rate for Payer: PHP Commercial |
$83.45
|
| Rate for Payer: Priority Health SBD |
$61.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.82
|
| Rate for Payer: UHC Core |
$51.15
|
| Rate for Payer: UHC Exchange |
$38.58
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$572.64
|
|
|
Service Code
|
NDC 60687043192
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.05 |
| Max. Negotiated Rate |
$515.38 |
| Rate for Payer: Aetna Commercial |
$486.74
|
| Rate for Payer: Aetna Medicare |
$286.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$372.22
|
| Rate for Payer: BCBS Complete |
$229.06
|
| Rate for Payer: Cash Price |
$458.11
|
| Rate for Payer: Cofinity Advantage |
$400.85
|
| Rate for Payer: Cofinity Commercial |
$492.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$458.11
|
| Rate for Payer: Healthscope Commercial |
$515.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$458.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$486.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$429.48
|
| Rate for Payer: PHP Commercial |
$486.74
|
| Rate for Payer: Priority Health SBD |
$360.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$372.22
|
| Rate for Payer: UHC Core |
$298.35
|
| Rate for Payer: UHC Exchange |
$225.05
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$8.34
|
|
|
Service Code
|
NDC 62559015717
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$7.51 |
| Rate for Payer: Aetna Commercial |
$7.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.42
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Cofinity Advantage |
$5.84
|
| Rate for Payer: Cofinity Commercial |
$7.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.67
|
| Rate for Payer: Healthscope Commercial |
$7.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.25
|
| Rate for Payer: PHP Commercial |
$7.09
|
| Rate for Payer: Priority Health SBD |
$5.25
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$7.02
|
|
|
Service Code
|
NDC 45802086800
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$6.32 |
| Rate for Payer: Aetna Commercial |
$5.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.56
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Cofinity Advantage |
$4.91
|
| Rate for Payer: Cofinity Commercial |
$6.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.62
|
| Rate for Payer: Healthscope Commercial |
$6.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.26
|
| Rate for Payer: PHP Commercial |
$5.97
|
| Rate for Payer: Priority Health SBD |
$4.42
|
|
