|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,371.70 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: BCBS Trust/PPO |
$11,769.41
|
| Rate for Payer: BCN Commercial |
$11,142.23
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,813.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,255.30
|
| Rate for Payer: Nomi Health Commercial |
$11,822.76
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,371.70
|
| Rate for Payer: Priority Health HMO/PPO |
$12,543.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9,660.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,687.84
|
| Rate for Payer: UHC Core |
$12,039.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,813.50
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: Aetna Medicare |
$3,748.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,505.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,505.62
|
| Rate for Payer: BCBS Complete |
$71.71
|
| Rate for Payer: BCBS MAPPO |
$3,604.50
|
| Rate for Payer: BCBS Trust/PPO |
$11,853.04
|
| Rate for Payer: BCN Commercial |
$11,210.00
|
| Rate for Payer: BCN Medicare Advantage |
$3,604.50
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,604.50
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,813.50
|
| Rate for Payer: Mclaren Medicaid |
$68.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,784.72
|
| Rate for Payer: Meridian Medicaid |
$71.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,145.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,255.30
|
| Rate for Payer: Nomi Health Commercial |
$11,822.76
|
| Rate for Payer: PACE Senior Care Partners |
$3,424.28
|
| Rate for Payer: PACE SWMI |
$3,604.50
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: PHP Medicare Advantage |
$3,604.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$68.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,371.70
|
| Rate for Payer: Priority Health HMO/PPO |
$12,543.66
|
| Rate for Payer: Priority Health Medicare |
$3,640.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9,660.06
|
| Rate for Payer: Railroad Medicare Medicare |
$3,604.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,687.84
|
| Rate for Payer: UHC Core |
$12,039.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,604.50
|
| Rate for Payer: UHC Exchange |
$3,604.50
|
| Rate for Payer: UHC Medicare Advantage |
$3,604.50
|
| Rate for Payer: UHCCP Medicaid |
$68.29
|
| Rate for Payer: VA VA |
$3,604.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,813.50
|
|
|
ALTEPLASE INFUSION FOR CARDIAC ARREST
|
Facility
|
IP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
300766
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,371.70 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: BCBS Trust/PPO |
$11,769.41
|
| Rate for Payer: BCN Commercial |
$11,142.23
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,813.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,255.30
|
| Rate for Payer: Nomi Health Commercial |
$11,822.76
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,371.70
|
| Rate for Payer: Priority Health HMO/PPO |
$12,543.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9,660.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,687.84
|
| Rate for Payer: UHC Core |
$12,039.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,813.50
|
|
|
ALTEPLASE INFUSION FOR CARDIAC ARREST
|
Facility
|
OP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
300766
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: Aetna Medicare |
$3,748.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,505.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,505.62
|
| Rate for Payer: BCBS Complete |
$71.71
|
| Rate for Payer: BCBS MAPPO |
$3,604.50
|
| Rate for Payer: BCBS Trust/PPO |
$11,853.04
|
| Rate for Payer: BCN Commercial |
$11,210.00
|
| Rate for Payer: BCN Medicare Advantage |
$3,604.50
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,604.50
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,813.50
|
| Rate for Payer: Mclaren Medicaid |
$68.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,784.72
|
| Rate for Payer: Meridian Medicaid |
$71.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,145.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,255.30
|
| Rate for Payer: Nomi Health Commercial |
$11,822.76
|
| Rate for Payer: PACE Senior Care Partners |
$3,424.28
|
| Rate for Payer: PACE SWMI |
$3,604.50
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: PHP Medicare Advantage |
$3,604.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$68.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,371.70
|
| Rate for Payer: Priority Health HMO/PPO |
$12,543.66
|
| Rate for Payer: Priority Health Medicare |
$3,640.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9,660.06
|
| Rate for Payer: Railroad Medicare Medicare |
$3,604.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,687.84
|
| Rate for Payer: UHC Core |
$12,039.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,604.50
|
| Rate for Payer: UHC Exchange |
$3,604.50
|
| Rate for Payer: UHC Medicare Advantage |
$3,604.50
|
| Rate for Payer: UHCCP Medicaid |
$68.29
|
| Rate for Payer: VA VA |
$3,604.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,813.50
|
|
|
ALTEPLASE IV BOLUS (FROM KIT)
|
Facility
|
OP
|
$71.71
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$71.71 |
| Rate for Payer: BCBS Complete |
$71.71
|
| Rate for Payer: Mclaren Medicaid |
$68.29
|
| Rate for Payer: Meridian Medicaid |
$71.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$68.29
|
| Rate for Payer: UHCCP Medicaid |
$68.29
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$12.83
|
|
|
Service Code
|
NDC 00904732573
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: BCBS Trust/PPO |
$10.47
|
| Rate for Payer: BCN Commercial |
$9.92
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: Nomi Health Commercial |
$10.52
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.34
|
| Rate for Payer: Priority Health HMO/PPO |
$11.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.29
|
| Rate for Payer: UHC Core |
$10.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.62
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 00904732573
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Aetna Medicare |
$3.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.01
|
| Rate for Payer: BCBS Complete |
$5.13
|
| Rate for Payer: BCBS MAPPO |
$3.21
|
| Rate for Payer: BCBS Trust/PPO |
$10.55
|
| Rate for Payer: BCN Commercial |
$9.98
|
| Rate for Payer: BCN Medicare Advantage |
$3.21
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.21
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: Nomi Health Commercial |
$10.52
|
| Rate for Payer: PACE Senior Care Partners |
$3.05
|
| Rate for Payer: PACE SWMI |
$3.21
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: PHP Medicare Advantage |
$3.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.34
|
| Rate for Payer: Priority Health HMO/PPO |
$11.16
|
| Rate for Payer: Priority Health Medicare |
$3.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.60
|
| Rate for Payer: Railroad Medicare Medicare |
$3.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.29
|
| Rate for Payer: UHC Core |
$10.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.21
|
| Rate for Payer: UHC Exchange |
$3.21
|
| Rate for Payer: UHC Medicare Advantage |
$3.21
|
| Rate for Payer: VA VA |
$3.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.62
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$11.33
|
|
|
Service Code
|
NDC 09900000191
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Aetna Commercial |
$9.63
|
| Rate for Payer: Aetna Medicare |
$2.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.54
|
| Rate for Payer: BCBS Complete |
$4.53
|
| Rate for Payer: BCBS MAPPO |
$2.83
|
| Rate for Payer: BCBS Trust/PPO |
$9.31
|
| Rate for Payer: BCN Commercial |
$8.81
|
| Rate for Payer: BCN Medicare Advantage |
$2.83
|
| Rate for Payer: Cash Price |
$9.06
|
| Rate for Payer: Cofinity Commercial |
$9.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.83
|
| Rate for Payer: Healthscope Commercial |
$10.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.63
|
| Rate for Payer: Nomi Health Commercial |
$9.29
|
| Rate for Payer: PACE Senior Care Partners |
$2.69
|
| Rate for Payer: PACE SWMI |
$2.83
|
| Rate for Payer: PHP Commercial |
$9.63
|
| Rate for Payer: PHP Medicare Advantage |
$2.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.36
|
| Rate for Payer: Priority Health HMO/PPO |
$9.86
|
| Rate for Payer: Priority Health Medicare |
$2.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.59
|
| Rate for Payer: Railroad Medicare Medicare |
$2.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.97
|
| Rate for Payer: UHC Core |
$9.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$2.83
|
| Rate for Payer: UHC Exchange |
$2.83
|
| Rate for Payer: UHC Medicare Advantage |
$2.83
|
| Rate for Payer: VA VA |
$2.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.50
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$13.77
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$12.39 |
| Rate for Payer: Aetna Commercial |
$11.70
|
| Rate for Payer: BCBS Trust/PPO |
$11.24
|
| Rate for Payer: BCN Commercial |
$10.64
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cofinity Commercial |
$11.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.02
|
| Rate for Payer: Healthscope Commercial |
$12.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.70
|
| Rate for Payer: Nomi Health Commercial |
$11.29
|
| Rate for Payer: PHP Commercial |
$11.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: Priority Health HMO/PPO |
$11.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.12
|
| Rate for Payer: UHC Core |
$11.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.33
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$15.98
|
|
|
Service Code
|
NDC 57896062912
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$14.38 |
| Rate for Payer: Aetna Commercial |
$13.58
|
| Rate for Payer: BCBS Trust/PPO |
$13.04
|
| Rate for Payer: BCN Commercial |
$12.35
|
| Rate for Payer: Cash Price |
$12.78
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.78
|
| Rate for Payer: Healthscope Commercial |
$14.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.58
|
| Rate for Payer: Nomi Health Commercial |
$13.10
|
| Rate for Payer: PHP Commercial |
$13.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.39
|
| Rate for Payer: Priority Health HMO/PPO |
$13.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.06
|
| Rate for Payer: UHC Core |
$13.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.98
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$13.77
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$12.39 |
| Rate for Payer: Aetna Commercial |
$11.70
|
| Rate for Payer: Aetna Medicare |
$3.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.30
|
| Rate for Payer: BCBS Complete |
$5.51
|
| Rate for Payer: BCBS MAPPO |
$3.44
|
| Rate for Payer: BCBS Trust/PPO |
$11.32
|
| Rate for Payer: BCN Commercial |
$10.71
|
| Rate for Payer: BCN Medicare Advantage |
$3.44
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cofinity Commercial |
$11.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.44
|
| Rate for Payer: Healthscope Commercial |
$12.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.70
|
| Rate for Payer: Nomi Health Commercial |
$11.29
|
| Rate for Payer: PACE Senior Care Partners |
$3.27
|
| Rate for Payer: PACE SWMI |
$3.44
|
| Rate for Payer: PHP Commercial |
$11.70
|
| Rate for Payer: PHP Medicare Advantage |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: Priority Health HMO/PPO |
$11.98
|
| Rate for Payer: Priority Health Medicare |
$3.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.23
|
| Rate for Payer: Railroad Medicare Medicare |
$3.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.12
|
| Rate for Payer: UHC Core |
$11.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.44
|
| Rate for Payer: UHC Exchange |
$3.44
|
| Rate for Payer: UHC Medicare Advantage |
$3.44
|
| Rate for Payer: VA VA |
$3.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.33
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 00904732562
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Aetna Medicare |
$3.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.01
|
| Rate for Payer: BCBS Complete |
$5.13
|
| Rate for Payer: BCBS MAPPO |
$3.21
|
| Rate for Payer: BCBS Trust/PPO |
$10.55
|
| Rate for Payer: BCN Commercial |
$9.98
|
| Rate for Payer: BCN Medicare Advantage |
$3.21
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.21
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: Nomi Health Commercial |
$10.52
|
| Rate for Payer: PACE Senior Care Partners |
$3.05
|
| Rate for Payer: PACE SWMI |
$3.21
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: PHP Medicare Advantage |
$3.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.34
|
| Rate for Payer: Priority Health HMO/PPO |
$11.16
|
| Rate for Payer: Priority Health Medicare |
$3.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.60
|
| Rate for Payer: Railroad Medicare Medicare |
$3.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.29
|
| Rate for Payer: UHC Core |
$10.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.21
|
| Rate for Payer: UHC Exchange |
$3.21
|
| Rate for Payer: UHC Medicare Advantage |
$3.21
|
| Rate for Payer: VA VA |
$3.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.62
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$11.33
|
|
|
Service Code
|
NDC 09900000191
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Aetna Commercial |
$9.63
|
| Rate for Payer: BCBS Trust/PPO |
$9.25
|
| Rate for Payer: BCN Commercial |
$8.76
|
| Rate for Payer: Cash Price |
$9.06
|
| Rate for Payer: Cofinity Commercial |
$9.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.06
|
| Rate for Payer: Healthscope Commercial |
$10.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.63
|
| Rate for Payer: Nomi Health Commercial |
$9.29
|
| Rate for Payer: PHP Commercial |
$9.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.36
|
| Rate for Payer: Priority Health HMO/PPO |
$9.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.97
|
| Rate for Payer: UHC Core |
$9.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.50
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$12.83
|
|
|
Service Code
|
NDC 00904732562
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: BCBS Trust/PPO |
$10.47
|
| Rate for Payer: BCN Commercial |
$9.92
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: Nomi Health Commercial |
$10.52
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.34
|
| Rate for Payer: Priority Health HMO/PPO |
$11.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.29
|
| Rate for Payer: UHC Core |
$10.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.62
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$15.98
|
|
|
Service Code
|
NDC 57896062912
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$14.38 |
| Rate for Payer: Aetna Commercial |
$13.58
|
| Rate for Payer: Aetna Medicare |
$4.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.99
|
| Rate for Payer: BCBS Complete |
$6.39
|
| Rate for Payer: BCBS MAPPO |
$4.00
|
| Rate for Payer: BCBS Trust/PPO |
$13.14
|
| Rate for Payer: BCN Commercial |
$12.42
|
| Rate for Payer: BCN Medicare Advantage |
$4.00
|
| Rate for Payer: Cash Price |
$12.78
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.00
|
| Rate for Payer: Healthscope Commercial |
$14.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.58
|
| Rate for Payer: Nomi Health Commercial |
$13.10
|
| Rate for Payer: PACE Senior Care Partners |
$3.80
|
| Rate for Payer: PACE SWMI |
$4.00
|
| Rate for Payer: PHP Commercial |
$13.58
|
| Rate for Payer: PHP Medicare Advantage |
$4.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.39
|
| Rate for Payer: Priority Health HMO/PPO |
$13.90
|
| Rate for Payer: Priority Health Medicare |
$4.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.71
|
| Rate for Payer: Railroad Medicare Medicare |
$4.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.06
|
| Rate for Payer: UHC Core |
$13.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.00
|
| Rate for Payer: UHC Exchange |
$4.00
|
| Rate for Payer: UHC Medicare Advantage |
$4.00
|
| Rate for Payer: VA VA |
$4.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.98
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
IP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919002010
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13,119.76 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: BCBS Trust/PPO |
$16,476.40
|
| Rate for Payer: BCN Commercial |
$15,598.38
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,147.39
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,138.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,156.60
|
| Rate for Payer: Nomi Health Commercial |
$16,551.08
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,119.76
|
| Rate for Payer: Priority Health HMO/PPO |
$17,560.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13,523.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,762.13
|
| Rate for Payer: UHC Core |
$16,853.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,138.18
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
|
OP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919002010
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,793.76 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: Aetna Medicare |
$5,247.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,307.57
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,307.57
|
| Rate for Payer: BCBS Complete |
$8,073.70
|
| Rate for Payer: BCBS MAPPO |
$5,046.06
|
| Rate for Payer: BCBS Trust/PPO |
$16,593.46
|
| Rate for Payer: BCN Commercial |
$15,693.25
|
| Rate for Payer: BCN Medicare Advantage |
$5,046.06
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,147.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,046.06
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,138.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,298.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,802.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17,156.60
|
| Rate for Payer: Nomi Health Commercial |
$16,551.08
|
| Rate for Payer: PACE Senior Care Partners |
$4,793.76
|
| Rate for Payer: PACE SWMI |
$5,046.06
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: PHP Medicare Advantage |
$5,046.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,119.76
|
| Rate for Payer: Priority Health HMO/PPO |
$17,560.29
|
| Rate for Payer: Priority Health Medicare |
$5,096.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13,523.44
|
| Rate for Payer: Railroad Medicare Medicare |
$5,046.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,762.13
|
| Rate for Payer: UHC Core |
$16,853.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,046.06
|
| Rate for Payer: UHC Exchange |
$5,046.06
|
| Rate for Payer: UHC Medicare Advantage |
$5,046.06
|
| Rate for Payer: VA VA |
$5,046.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,138.18
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$165.30
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.26 |
| Max. Negotiated Rate |
$148.77 |
| Rate for Payer: Aetna Commercial |
$140.50
|
| Rate for Payer: Aetna Medicare |
$42.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$51.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$51.66
|
| Rate for Payer: BCBS Complete |
$66.12
|
| Rate for Payer: BCBS MAPPO |
$41.33
|
| Rate for Payer: BCBS Trust/PPO |
$135.89
|
| Rate for Payer: BCN Commercial |
$128.52
|
| Rate for Payer: BCN Medicare Advantage |
$41.33
|
| Rate for Payer: Cash Price |
$132.24
|
| Rate for Payer: Cofinity Commercial |
$142.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.33
|
| Rate for Payer: Healthscope Commercial |
$148.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$43.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.50
|
| Rate for Payer: Nomi Health Commercial |
$135.55
|
| Rate for Payer: PACE Senior Care Partners |
$39.26
|
| Rate for Payer: PACE SWMI |
$41.33
|
| Rate for Payer: PHP Commercial |
$140.50
|
| Rate for Payer: PHP Medicare Advantage |
$41.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.44
|
| Rate for Payer: Priority Health HMO/PPO |
$143.81
|
| Rate for Payer: Priority Health Medicare |
$41.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$110.75
|
| Rate for Payer: Railroad Medicare Medicare |
$41.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$145.46
|
| Rate for Payer: UHC Core |
$138.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.33
|
| Rate for Payer: UHC Exchange |
$41.33
|
| Rate for Payer: UHC Medicare Advantage |
$41.33
|
| Rate for Payer: VA VA |
$41.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.97
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$165.30
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.44 |
| Max. Negotiated Rate |
$148.77 |
| Rate for Payer: Aetna Commercial |
$140.50
|
| Rate for Payer: BCBS Trust/PPO |
$134.93
|
| Rate for Payer: BCN Commercial |
$127.74
|
| Rate for Payer: Cash Price |
$132.24
|
| Rate for Payer: Cofinity Commercial |
$142.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.24
|
| Rate for Payer: Healthscope Commercial |
$148.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.50
|
| Rate for Payer: Nomi Health Commercial |
$135.55
|
| Rate for Payer: PHP Commercial |
$140.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.44
|
| Rate for Payer: Priority Health HMO/PPO |
$143.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$110.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$145.46
|
| Rate for Payer: UHC Core |
$138.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.97
|
|
|
AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$32.76
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
113386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.29 |
| Max. Negotiated Rate |
$29.48 |
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: BCBS Trust/PPO |
$26.74
|
| Rate for Payer: BCN Commercial |
$25.32
|
| Rate for Payer: Cash Price |
$26.21
|
| Rate for Payer: Cofinity Commercial |
$28.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.21
|
| Rate for Payer: Healthscope Commercial |
$29.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.85
|
| Rate for Payer: Nomi Health Commercial |
$26.86
|
| Rate for Payer: PHP Commercial |
$27.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.29
|
| Rate for Payer: Priority Health HMO/PPO |
$28.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.83
|
| Rate for Payer: UHC Core |
$27.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.57
|
|
|
AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$32.76
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
113386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$29.48 |
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: Aetna Medicare |
$8.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.24
|
| Rate for Payer: BCBS Complete |
$13.10
|
| Rate for Payer: BCBS MAPPO |
$8.19
|
| Rate for Payer: BCBS Trust/PPO |
$26.93
|
| Rate for Payer: BCN Commercial |
$25.47
|
| Rate for Payer: BCN Medicare Advantage |
$8.19
|
| Rate for Payer: Cash Price |
$26.21
|
| Rate for Payer: Cofinity Commercial |
$28.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.19
|
| Rate for Payer: Healthscope Commercial |
$29.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.85
|
| Rate for Payer: Nomi Health Commercial |
$26.86
|
| Rate for Payer: PACE Senior Care Partners |
$7.78
|
| Rate for Payer: PACE SWMI |
$8.19
|
| Rate for Payer: PHP Commercial |
$27.85
|
| Rate for Payer: PHP Medicare Advantage |
$8.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.29
|
| Rate for Payer: Priority Health HMO/PPO |
$28.50
|
| Rate for Payer: Priority Health Medicare |
$8.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.95
|
| Rate for Payer: Railroad Medicare Medicare |
$8.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.83
|
| Rate for Payer: UHC Core |
$27.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.19
|
| Rate for Payer: UHC Exchange |
$8.19
|
| Rate for Payer: UHC Medicare Advantage |
$8.19
|
| Rate for Payer: VA VA |
$8.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.57
|
|
|
AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
|
IP
|
$93.90
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.03 |
| Max. Negotiated Rate |
$84.51 |
| Rate for Payer: Aetna Commercial |
$79.81
|
| Rate for Payer: BCBS Trust/PPO |
$76.65
|
| Rate for Payer: BCN Commercial |
$72.57
|
| Rate for Payer: Cash Price |
$75.12
|
| Rate for Payer: Cofinity Commercial |
$80.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.12
|
| Rate for Payer: Healthscope Commercial |
$84.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.81
|
| Rate for Payer: Nomi Health Commercial |
$77.00
|
| Rate for Payer: PHP Commercial |
$79.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.03
|
| Rate for Payer: Priority Health HMO/PPO |
$81.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$62.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$82.63
|
| Rate for Payer: UHC Core |
$78.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.42
|
|
|
AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
|
OP
|
$93.90
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.30 |
| Max. Negotiated Rate |
$84.51 |
| Rate for Payer: Aetna Commercial |
$79.81
|
| Rate for Payer: Aetna Medicare |
$24.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.34
|
| Rate for Payer: BCBS Complete |
$37.56
|
| Rate for Payer: BCBS MAPPO |
$23.48
|
| Rate for Payer: BCBS Trust/PPO |
$77.20
|
| Rate for Payer: BCN Commercial |
$73.01
|
| Rate for Payer: BCN Medicare Advantage |
$23.48
|
| Rate for Payer: Cash Price |
$75.12
|
| Rate for Payer: Cofinity Commercial |
$80.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.48
|
| Rate for Payer: Healthscope Commercial |
$84.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.81
|
| Rate for Payer: Nomi Health Commercial |
$77.00
|
| Rate for Payer: PACE Senior Care Partners |
$22.30
|
| Rate for Payer: PACE SWMI |
$23.48
|
| Rate for Payer: PHP Commercial |
$79.81
|
| Rate for Payer: PHP Medicare Advantage |
$23.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.03
|
| Rate for Payer: Priority Health HMO/PPO |
$81.69
|
| Rate for Payer: Priority Health Medicare |
$23.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$62.91
|
| Rate for Payer: Railroad Medicare Medicare |
$23.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$82.63
|
| Rate for Payer: UHC Core |
$78.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.48
|
| Rate for Payer: UHC Exchange |
$23.48
|
| Rate for Payer: UHC Medicare Advantage |
$23.48
|
| Rate for Payer: VA VA |
$23.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.42
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 00245014789
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Aetna Commercial |
$1.75
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.64
|
| Rate for Payer: BCBS Complete |
$0.82
|
| Rate for Payer: BCBS MAPPO |
$0.52
|
| Rate for Payer: BCBS Trust/PPO |
$1.69
|
| Rate for Payer: BCN Commercial |
$1.60
|
| Rate for Payer: BCN Medicare Advantage |
$0.52
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cofinity Commercial |
$1.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.52
|
| Rate for Payer: Healthscope Commercial |
$1.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.75
|
| Rate for Payer: Nomi Health Commercial |
$1.69
|
| Rate for Payer: PACE Senior Care Partners |
$0.49
|
| Rate for Payer: PACE SWMI |
$0.52
|
| Rate for Payer: PHP Commercial |
$1.75
|
| Rate for Payer: PHP Medicare Advantage |
$0.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.34
|
| Rate for Payer: Priority Health HMO/PPO |
$1.79
|
| Rate for Payer: Priority Health Medicare |
$0.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.38
|
| Rate for Payer: Railroad Medicare Medicare |
$0.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.81
|
| Rate for Payer: UHC Core |
$1.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.52
|
| Rate for Payer: UHC Exchange |
$0.52
|
| Rate for Payer: UHC Medicare Advantage |
$0.52
|
| Rate for Payer: VA VA |
$0.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.54
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
|
IP
|
$205.20
|
|
|
Service Code
|
NDC 00245014701
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.38 |
| Max. Negotiated Rate |
$184.68 |
| Rate for Payer: Aetna Commercial |
$174.42
|
| Rate for Payer: BCBS Trust/PPO |
$167.50
|
| Rate for Payer: BCN Commercial |
$158.58
|
| Rate for Payer: Cash Price |
$164.16
|
| Rate for Payer: Cofinity Commercial |
$176.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.16
|
| Rate for Payer: Healthscope Commercial |
$184.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.42
|
| Rate for Payer: Nomi Health Commercial |
$168.26
|
| Rate for Payer: PHP Commercial |
$174.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.38
|
| Rate for Payer: Priority Health HMO/PPO |
$178.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$137.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$180.58
|
| Rate for Payer: UHC Core |
$171.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.90
|
|
