|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC
|
Facility
|
IP
|
$40,584.62
|
|
|
Service Code
|
MS-DRG 982
|
| Min. Negotiated Rate |
$17,476.57 |
| Max. Negotiated Rate |
$40,584.62 |
| Rate for Payer: Aetna Medicare |
$19,132.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22,995.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22,995.49
|
| Rate for Payer: BCBS MAPPO |
$18,396.39
|
| Rate for Payer: BCBS Trust/PPO |
$40,584.62
|
| Rate for Payer: BCN Medicare Advantage |
$18,396.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18,396.39
|
| Rate for Payer: Mclaren Medicare |
$18,396.39
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19,316.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21,155.85
|
| Rate for Payer: PACE Medicare |
$17,476.57
|
| Rate for Payer: PACE SWMI |
$18,396.39
|
| Rate for Payer: PHP Medicare Advantage |
$18,396.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$35,673.90
|
| Rate for Payer: Priority Health Medicare |
$18,396.39
|
| Rate for Payer: Priority Health Narrow Network |
$28,539.12
|
| Rate for Payer: Railroad Medicare Medicare |
$18,396.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37,921.44
|
| Rate for Payer: UHC Core |
$23,268.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$18,396.39
|
| Rate for Payer: UHC Exchange |
$24,922.15
|
| Rate for Payer: UHC Medicare Advantage |
$18,948.28
|
| Rate for Payer: VA VA |
$18,396.39
|
|
|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC
|
Facility
|
IP
|
$96,707.44
|
|
|
Service Code
|
MS-DRG 981
|
| Min. Negotiated Rate |
$32,900.49 |
| Max. Negotiated Rate |
$96,707.44 |
| Rate for Payer: Aetna Medicare |
$36,017.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$43,290.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$43,290.11
|
| Rate for Payer: BCBS MAPPO |
$34,632.09
|
| Rate for Payer: BCBS Trust/PPO |
$96,707.44
|
| Rate for Payer: BCN Medicare Advantage |
$34,632.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34,632.09
|
| Rate for Payer: Mclaren Medicare |
$34,632.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$36,363.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39,826.90
|
| Rate for Payer: PACE Medicare |
$32,900.49
|
| Rate for Payer: PACE SWMI |
$34,632.09
|
| Rate for Payer: PHP Medicare Advantage |
$34,632.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$68,024.36
|
| Rate for Payer: Priority Health Medicare |
$34,632.09
|
| Rate for Payer: Priority Health Narrow Network |
$54,419.49
|
| Rate for Payer: Railroad Medicare Medicare |
$34,632.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$72,310.06
|
| Rate for Payer: UHC Core |
$44,370.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$34,632.09
|
| Rate for Payer: UHC Exchange |
$47,522.51
|
| Rate for Payer: UHC Medicare Advantage |
$35,671.05
|
| Rate for Payer: VA VA |
$34,632.09
|
|
|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$30,793.11
|
|
|
Service Code
|
MS-DRG 983
|
| Min. Negotiated Rate |
$11,655.65 |
| Max. Negotiated Rate |
$30,793.11 |
| Rate for Payer: Aetna Medicare |
$12,759.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,336.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,336.39
|
| Rate for Payer: BCBS MAPPO |
$12,269.11
|
| Rate for Payer: BCBS Trust/PPO |
$30,793.11
|
| Rate for Payer: BCN Medicare Advantage |
$12,269.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,269.11
|
| Rate for Payer: Mclaren Medicare |
$12,269.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,882.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,109.48
|
| Rate for Payer: PACE Medicare |
$11,655.65
|
| Rate for Payer: PACE SWMI |
$12,269.11
|
| Rate for Payer: PHP Medicare Advantage |
$12,269.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23,464.99
|
| Rate for Payer: Priority Health Medicare |
$12,269.11
|
| Rate for Payer: Priority Health Narrow Network |
$18,771.99
|
| Rate for Payer: Railroad Medicare Medicare |
$12,269.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,943.34
|
| Rate for Payer: UHC Core |
$15,305.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,269.11
|
| Rate for Payer: UHC Exchange |
$16,392.88
|
| Rate for Payer: UHC Medicare Advantage |
$12,637.18
|
| Rate for Payer: VA VA |
$12,269.11
|
|
|
EXTRACRANIAL PROCEDURES WITH CC
|
Facility
|
IP
|
$27,470.71
|
|
|
Service Code
|
MS-DRG 038
|
| Min. Negotiated Rate |
$11,414.14 |
| Max. Negotiated Rate |
$27,470.71 |
| Rate for Payer: Aetna Medicare |
$12,495.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,018.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,018.60
|
| Rate for Payer: BCBS MAPPO |
$12,014.88
|
| Rate for Payer: BCBS Trust/PPO |
$27,470.71
|
| Rate for Payer: BCN Medicare Advantage |
$12,014.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,014.88
|
| Rate for Payer: Mclaren Medicare |
$12,014.88
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,615.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,817.11
|
| Rate for Payer: PACE Medicare |
$11,414.14
|
| Rate for Payer: PACE SWMI |
$12,014.88
|
| Rate for Payer: PHP Medicare Advantage |
$12,014.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,958.44
|
| Rate for Payer: Priority Health Medicare |
$12,014.88
|
| Rate for Payer: Priority Health Narrow Network |
$18,366.75
|
| Rate for Payer: Railroad Medicare Medicare |
$12,014.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,404.87
|
| Rate for Payer: UHC Core |
$14,975.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,014.88
|
| Rate for Payer: UHC Exchange |
$16,039.00
|
| Rate for Payer: UHC Medicare Advantage |
$12,375.33
|
| Rate for Payer: VA VA |
$12,014.88
|
|
|
EXTRACRANIAL PROCEDURES WITH MCC
|
Facility
|
IP
|
$51,491.40
|
|
|
Service Code
|
MS-DRG 037
|
| Min. Negotiated Rate |
$23,562.94 |
| Max. Negotiated Rate |
$51,491.40 |
| Rate for Payer: Aetna Medicare |
$25,795.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31,003.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31,003.86
|
| Rate for Payer: BCBS MAPPO |
$24,803.09
|
| Rate for Payer: BCBS Trust/PPO |
$41,675.99
|
| Rate for Payer: BCN Medicare Advantage |
$24,803.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24,803.09
|
| Rate for Payer: Mclaren Medicare |
$24,803.09
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$26,043.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28,523.55
|
| Rate for Payer: PACE Medicare |
$23,562.94
|
| Rate for Payer: PACE SWMI |
$24,803.09
|
| Rate for Payer: PHP Medicare Advantage |
$24,803.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$48,439.59
|
| Rate for Payer: Priority Health Medicare |
$24,803.09
|
| Rate for Payer: Priority Health Narrow Network |
$38,751.67
|
| Rate for Payer: Railroad Medicare Medicare |
$24,803.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51,491.40
|
| Rate for Payer: UHC Core |
$31,595.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$24,803.09
|
| Rate for Payer: UHC Exchange |
$33,840.39
|
| Rate for Payer: UHC Medicare Advantage |
$25,547.18
|
| Rate for Payer: VA VA |
$24,803.09
|
|
|
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$26,537.45
|
|
|
Service Code
|
MS-DRG 039
|
| Min. Negotiated Rate |
$8,274.48 |
| Max. Negotiated Rate |
$26,537.45 |
| Rate for Payer: Aetna Medicare |
$9,058.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,887.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,887.48
|
| Rate for Payer: BCBS MAPPO |
$8,709.98
|
| Rate for Payer: BCBS Trust/PPO |
$26,537.45
|
| Rate for Payer: BCN Medicare Advantage |
$8,709.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,709.98
|
| Rate for Payer: Mclaren Medicare |
$8,709.98
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,145.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,016.48
|
| Rate for Payer: PACE Medicare |
$8,274.48
|
| Rate for Payer: PACE SWMI |
$8,709.98
|
| Rate for Payer: PHP Medicare Advantage |
$8,709.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,373.26
|
| Rate for Payer: Priority Health Medicare |
$8,709.98
|
| Rate for Payer: Priority Health Narrow Network |
$13,098.61
|
| Rate for Payer: Railroad Medicare Medicare |
$8,709.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,404.81
|
| Rate for Payer: UHC Core |
$10,679.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$8,709.98
|
| Rate for Payer: UHC Exchange |
$11,438.53
|
| Rate for Payer: UHC Medicare Advantage |
$8,971.28
|
| Rate for Payer: VA VA |
$8,709.98
|
|
|
EXTRAOCULAR PROCEDURES EXCEPT ORBIT
|
Facility
|
IP
|
$23,863.36
|
|
|
Service Code
|
MS-DRG 115
|
| Min. Negotiated Rate |
$11,171.26 |
| Max. Negotiated Rate |
$23,863.36 |
| Rate for Payer: Aetna Medicare |
$12,229.59
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,699.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,699.02
|
| Rate for Payer: BCBS MAPPO |
$11,759.22
|
| Rate for Payer: BCBS Trust/PPO |
$16,620.77
|
| Rate for Payer: BCN Medicare Advantage |
$11,759.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,759.22
|
| Rate for Payer: Mclaren Medicare |
$11,759.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,347.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,523.10
|
| Rate for Payer: PACE Medicare |
$11,171.26
|
| Rate for Payer: PACE SWMI |
$11,759.22
|
| Rate for Payer: PHP Medicare Advantage |
$11,759.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,449.01
|
| Rate for Payer: Priority Health Medicare |
$11,759.22
|
| Rate for Payer: Priority Health Narrow Network |
$17,959.21
|
| Rate for Payer: Railroad Medicare Medicare |
$11,759.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23,863.36
|
| Rate for Payer: UHC Core |
$14,642.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,759.22
|
| Rate for Payer: UHC Exchange |
$15,683.11
|
| Rate for Payer: UHC Medicare Advantage |
$12,112.00
|
| Rate for Payer: VA VA |
$11,759.22
|
|
|
EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE
|
Facility
|
IP
|
$91,525.53
|
|
|
Service Code
|
MS-DRG 790
|
| Min. Negotiated Rate |
$827.00 |
| Max. Negotiated Rate |
$91,525.53 |
| Rate for Payer: Aetna Medicare |
$45,452.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$54,630.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$54,630.26
|
| Rate for Payer: BCBS MAPPO |
$43,704.21
|
| Rate for Payer: BCBS Trust/PPO |
$18,845.21
|
| Rate for Payer: BCN Medicare Advantage |
$43,704.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$43,704.21
|
| Rate for Payer: Mclaren Medicare |
$43,704.21
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$45,889.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$50,259.84
|
| Rate for Payer: PACE Medicare |
$41,519.00
|
| Rate for Payer: PACE SWMI |
$43,704.21
|
| Rate for Payer: PHP Medicare Advantage |
$43,704.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$86,100.95
|
| Rate for Payer: Priority Health Medicare |
$43,704.21
|
| Rate for Payer: Priority Health Narrow Network |
$68,880.76
|
| Rate for Payer: Railroad Medicare Medicare |
$43,704.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$91,525.53
|
| Rate for Payer: UHC Core |
$827.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$43,704.21
|
| Rate for Payer: UHC Medicare Advantage |
$45,015.34
|
| Rate for Payer: VA VA |
$43,704.21
|
|
|
EYELASH TINTING
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 00176
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: BCBS Complete |
$12.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.00
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$26.45
|
|
|
Service Code
|
NDC 60687-373-11
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna Commercial |
$22.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.19
|
| Rate for Payer: Cash Price |
$21.16
|
| Rate for Payer: Cofinity Commercial |
$18.52
|
| Rate for Payer: Cofinity Commercial |
$22.75
|
| Rate for Payer: Healthscope Commercial |
$23.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.48
|
| Rate for Payer: PHP Commercial |
$22.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.52
|
| Rate for Payer: Priority Health SBD |
$16.66
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$66.27
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.75 |
| Max. Negotiated Rate |
$59.64 |
| Rate for Payer: Aetna Commercial |
$56.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.08
|
| Rate for Payer: Cash Price |
$53.02
|
| Rate for Payer: Cofinity Commercial |
$46.39
|
| Rate for Payer: Cofinity Commercial |
$56.99
|
| Rate for Payer: Healthscope Commercial |
$59.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.33
|
| Rate for Payer: PHP Commercial |
$56.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.39
|
| Rate for Payer: Priority Health SBD |
$41.75
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$793.21
|
|
|
Service Code
|
NDC 60687-373-21
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$499.72 |
| Max. Negotiated Rate |
$713.89 |
| Rate for Payer: Aetna Commercial |
$674.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$515.59
|
| Rate for Payer: Cash Price |
$634.57
|
| Rate for Payer: Cofinity Commercial |
$555.25
|
| Rate for Payer: Cofinity Commercial |
$682.16
|
| Rate for Payer: Healthscope Commercial |
$713.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$674.23
|
| Rate for Payer: PHP Commercial |
$674.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$555.25
|
| Rate for Payer: Priority Health SBD |
$499.72
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$76.95
|
|
|
Service Code
|
NDC 0781-5690-31
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.48 |
| Max. Negotiated Rate |
$69.26 |
| Rate for Payer: Aetna Commercial |
$65.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.02
|
| Rate for Payer: Cash Price |
$61.56
|
| Rate for Payer: Cofinity Commercial |
$53.86
|
| Rate for Payer: Cofinity Commercial |
$66.18
|
| Rate for Payer: Healthscope Commercial |
$69.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.41
|
| Rate for Payer: PHP Commercial |
$65.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.86
|
| Rate for Payer: Priority Health SBD |
$48.48
|
|
|
FACIAL
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 00174
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: BCBS Complete |
$26.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$204.50
|
|
|
Service Code
|
NDC 67457-457-00
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.84 |
| Max. Negotiated Rate |
$184.05 |
| Rate for Payer: Aetna Commercial |
$173.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.92
|
| Rate for Payer: Cash Price |
$163.60
|
| Rate for Payer: Cofinity Commercial |
$143.15
|
| Rate for Payer: Cofinity Commercial |
$175.87
|
| Rate for Payer: Healthscope Commercial |
$184.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$173.82
|
| Rate for Payer: PHP Commercial |
$173.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.15
|
| Rate for Payer: Priority Health SBD |
$128.84
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
NDC 0641-6021-01
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.22 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Aetna Commercial |
$164.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.10
|
| Rate for Payer: Cash Price |
$155.20
|
| Rate for Payer: Cofinity Commercial |
$135.80
|
| Rate for Payer: Cofinity Commercial |
$166.84
|
| Rate for Payer: Healthscope Commercial |
$174.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$164.90
|
| Rate for Payer: PHP Commercial |
$164.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.80
|
| Rate for Payer: Priority Health SBD |
$122.22
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$37.40
|
|
|
Service Code
|
NDC 63323-738-09
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna Commercial |
$31.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.31
|
| Rate for Payer: BCBS Complete |
$14.96
|
| Rate for Payer: Cash Price |
$29.92
|
| Rate for Payer: Cofinity Commercial |
$26.18
|
| Rate for Payer: Cofinity Commercial |
$32.16
|
| Rate for Payer: Healthscope Commercial |
$33.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.79
|
| Rate for Payer: PHP Commercial |
$31.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.18
|
| Rate for Payer: Priority Health SBD |
$23.56
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$204.50
|
|
|
Service Code
|
NDC 67457-457-20
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.84 |
| Max. Negotiated Rate |
$184.05 |
| Rate for Payer: Aetna Commercial |
$173.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.92
|
| Rate for Payer: Cash Price |
$163.60
|
| Rate for Payer: Cofinity Commercial |
$143.15
|
| Rate for Payer: Cofinity Commercial |
$175.87
|
| Rate for Payer: Healthscope Commercial |
$184.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$173.82
|
| Rate for Payer: PHP Commercial |
$173.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.15
|
| Rate for Payer: Priority Health SBD |
$128.84
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
NDC 0641-6021-10
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.22 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Aetna Commercial |
$164.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.10
|
| Rate for Payer: Cash Price |
$155.20
|
| Rate for Payer: Cofinity Commercial |
$135.80
|
| Rate for Payer: Cofinity Commercial |
$166.84
|
| Rate for Payer: Healthscope Commercial |
$174.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$164.90
|
| Rate for Payer: PHP Commercial |
$164.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.80
|
| Rate for Payer: Priority Health SBD |
$122.22
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
NDC 0641-6021-01
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.22 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Aetna Commercial |
$164.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.10
|
| Rate for Payer: Cash Price |
$155.20
|
| Rate for Payer: Cofinity Commercial |
$135.80
|
| Rate for Payer: Cofinity Commercial |
$166.84
|
| Rate for Payer: Healthscope Commercial |
$174.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$164.90
|
| Rate for Payer: PHP Commercial |
$164.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.80
|
| Rate for Payer: Priority Health SBD |
$122.22
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 70000-0503-1
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.01 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.12
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 50268-303-11
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna Commercial |
$1.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.44
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$1.55
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Healthscope Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.88
|
| Rate for Payer: PHP Commercial |
$1.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
| Rate for Payer: Priority Health SBD |
$1.39
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$1,365.08
|
|
|
Service Code
|
NDC 0187-4420-30
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$860.00 |
| Max. Negotiated Rate |
$1,228.57 |
| Rate for Payer: Aetna Commercial |
$1,160.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$887.30
|
| Rate for Payer: Cash Price |
$1,092.06
|
| Rate for Payer: Cofinity Commercial |
$1,173.97
|
| Rate for Payer: Cofinity Commercial |
$955.56
|
| Rate for Payer: Healthscope Commercial |
$1,228.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,160.32
|
| Rate for Payer: PHP Commercial |
$1,160.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$955.56
|
| Rate for Payer: Priority Health SBD |
$860.00
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
|
Service Code
|
NDC 61442-121-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.75 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$127.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.76
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$129.34
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.84
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.28
|
| Rate for Payer: Priority Health SBD |
$94.75
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$109.28
|
|
|
Service Code
|
NDC 0904-7193-06
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.85 |
| Max. Negotiated Rate |
$98.35 |
| Rate for Payer: Aetna Commercial |
$92.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.03
|
| Rate for Payer: Cash Price |
$87.42
|
| Rate for Payer: Cofinity Commercial |
$76.50
|
| Rate for Payer: Cofinity Commercial |
$93.98
|
| Rate for Payer: Healthscope Commercial |
$98.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$92.89
|
| Rate for Payer: PHP Commercial |
$92.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.50
|
| Rate for Payer: Priority Health SBD |
$68.85
|
|
