|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$389.98
|
|
|
Service Code
|
NDC 50268005415
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.29 |
| Max. Negotiated Rate |
$389.98 |
| Rate for Payer: Aetna Commercial |
$350.98
|
| Rate for Payer: Aetna Medicare |
$144.29
|
| Rate for Payer: ASR ASR |
$378.28
|
| Rate for Payer: BCBS Complete |
$155.99
|
| Rate for Payer: BCBS Trust/PPO |
$321.54
|
| Rate for Payer: BCN Commercial |
$321.54
|
| Rate for Payer: Cash Price |
$311.98
|
| Rate for Payer: Cofinity Commercial |
$366.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.98
|
| Rate for Payer: Healthscope Commercial |
$378.28
|
| Rate for Payer: Healthscope Whirlpool |
$389.98
|
| Rate for Payer: Mclaren Commercial |
$350.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$311.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.48
|
| Rate for Payer: Nomi Health Commercial |
$319.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$341.70
|
| Rate for Payer: Priority Health Narrow Network |
$273.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$343.18
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$7.80
|
|
|
Service Code
|
NDC 50268005411
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: ASR ASR |
$7.57
|
| Rate for Payer: BCBS Trust/PPO |
$6.41
|
| Rate for Payer: BCN Commercial |
$6.41
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cofinity Commercial |
$7.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Healthscope Commercial |
$7.57
|
| Rate for Payer: Healthscope Whirlpool |
$7.80
|
| Rate for Payer: Mclaren Commercial |
$7.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.63
|
| Rate for Payer: Nomi Health Commercial |
$6.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.86
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$309.70
|
|
|
Service Code
|
NDC 23155028801
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.28 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$278.73
|
| Rate for Payer: ASR ASR |
$300.41
|
| Rate for Payer: BCBS Trust/PPO |
$254.33
|
| Rate for Payer: BCN Commercial |
$254.33
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$291.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$300.41
|
| Rate for Payer: Healthscope Whirlpool |
$309.70
|
| Rate for Payer: Mclaren Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.25
|
| Rate for Payer: Nomi Health Commercial |
$253.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$272.54
|
|
|
ACETIC ACID (BULK) 3 % LIQUID
|
Facility
|
OP
|
$258.00
|
|
|
Service Code
|
NDC 51552005106
|
| Hospital Charge Code |
15091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.46 |
| Max. Negotiated Rate |
$258.00 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Aetna Medicare |
$95.46
|
| Rate for Payer: ASR ASR |
$250.26
|
| Rate for Payer: BCBS Complete |
$103.20
|
| Rate for Payer: BCBS Trust/PPO |
$212.72
|
| Rate for Payer: BCN Commercial |
$212.72
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.40
|
| Rate for Payer: Healthscope Commercial |
$250.26
|
| Rate for Payer: Healthscope Whirlpool |
$258.00
|
| Rate for Payer: Mclaren Commercial |
$232.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$206.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.30
|
| Rate for Payer: Nomi Health Commercial |
$211.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$193.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$226.06
|
| Rate for Payer: Priority Health Narrow Network |
$180.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$227.04
|
|
|
ACETIC ACID (BULK) 3 % LIQUID
|
Facility
|
IP
|
$258.00
|
|
|
Service Code
|
NDC 51552005106
|
| Hospital Charge Code |
15091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.50 |
| Max. Negotiated Rate |
$258.00 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: ASR ASR |
$250.26
|
| Rate for Payer: BCBS Trust/PPO |
$211.87
|
| Rate for Payer: BCN Commercial |
$211.87
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.40
|
| Rate for Payer: Healthscope Commercial |
$250.26
|
| Rate for Payer: Healthscope Whirlpool |
$258.00
|
| Rate for Payer: Mclaren Commercial |
$232.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.30
|
| Rate for Payer: Nomi Health Commercial |
$211.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$193.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$227.04
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$95.19
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$95.19 |
| Rate for Payer: Aetna Commercial |
$85.67
|
| Rate for Payer: Aetna Commercial |
$73.05
|
| Rate for Payer: Aetna Commercial |
$77.26
|
| Rate for Payer: Aetna Commercial |
$92.64
|
| Rate for Payer: Aetna Medicare |
$38.08
|
| Rate for Payer: Aetna Medicare |
$35.22
|
| Rate for Payer: Aetna Medicare |
$31.76
|
| Rate for Payer: Aetna Medicare |
$30.03
|
| Rate for Payer: ASR ASR |
$83.27
|
| Rate for Payer: ASR ASR |
$78.73
|
| Rate for Payer: ASR ASR |
$99.84
|
| Rate for Payer: ASR ASR |
$92.33
|
| Rate for Payer: BCBS Complete |
$34.34
|
| Rate for Payer: BCBS Complete |
$41.17
|
| Rate for Payer: BCBS Complete |
$38.07
|
| Rate for Payer: BCBS Complete |
$32.47
|
| Rate for Payer: BCBS Trust/PPO |
$66.92
|
| Rate for Payer: BCBS Trust/PPO |
$78.48
|
| Rate for Payer: BCBS Trust/PPO |
$70.78
|
| Rate for Payer: BCBS Trust/PPO |
$84.86
|
| Rate for Payer: BCN Commercial |
$78.48
|
| Rate for Payer: BCN Commercial |
$70.78
|
| Rate for Payer: BCN Commercial |
$84.86
|
| Rate for Payer: BCN Commercial |
$66.92
|
| Rate for Payer: Cash Price |
$82.34
|
| Rate for Payer: Cash Price |
$68.67
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$64.93
|
| Rate for Payer: Cash Price |
$64.93
|
| Rate for Payer: Cash Price |
$82.34
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$68.67
|
| Rate for Payer: Cofinity Commercial |
$89.47
|
| Rate for Payer: Cofinity Commercial |
$96.75
|
| Rate for Payer: Cofinity Commercial |
$80.69
|
| Rate for Payer: Cofinity Commercial |
$76.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.67
|
| Rate for Payer: Healthscope Commercial |
$92.33
|
| Rate for Payer: Healthscope Commercial |
$99.84
|
| Rate for Payer: Healthscope Commercial |
$78.73
|
| Rate for Payer: Healthscope Commercial |
$83.27
|
| Rate for Payer: Healthscope Whirlpool |
$102.93
|
| Rate for Payer: Healthscope Whirlpool |
$85.84
|
| Rate for Payer: Healthscope Whirlpool |
$95.19
|
| Rate for Payer: Healthscope Whirlpool |
$81.17
|
| Rate for Payer: Mclaren Commercial |
$77.26
|
| Rate for Payer: Mclaren Commercial |
$73.05
|
| Rate for Payer: Mclaren Commercial |
$92.64
|
| Rate for Payer: Mclaren Commercial |
$85.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$64.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.91
|
| Rate for Payer: Nomi Health Commercial |
$84.40
|
| Rate for Payer: Nomi Health Commercial |
$70.39
|
| Rate for Payer: Nomi Health Commercial |
$78.05
|
| Rate for Payer: Nomi Health Commercial |
$66.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$60.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.38
|
| Rate for Payer: Priority Health Narrow Network |
$0.30
|
| Rate for Payer: Priority Health Narrow Network |
$0.30
|
| Rate for Payer: Priority Health Narrow Network |
$0.30
|
| Rate for Payer: Priority Health Narrow Network |
$0.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$90.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$71.43
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$85.84
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.38 |
| Max. Negotiated Rate |
$85.84 |
| Rate for Payer: Aetna Commercial |
$77.26
|
| Rate for Payer: Aetna Commercial |
$73.05
|
| Rate for Payer: Aetna Commercial |
$85.67
|
| Rate for Payer: Aetna Commercial |
$92.64
|
| Rate for Payer: ASR ASR |
$92.33
|
| Rate for Payer: ASR ASR |
$83.27
|
| Rate for Payer: ASR ASR |
$78.73
|
| Rate for Payer: ASR ASR |
$99.84
|
| Rate for Payer: BCBS Trust/PPO |
$70.49
|
| Rate for Payer: BCBS Trust/PPO |
$84.53
|
| Rate for Payer: BCBS Trust/PPO |
$66.66
|
| Rate for Payer: BCBS Trust/PPO |
$78.17
|
| Rate for Payer: BCN Commercial |
$84.53
|
| Rate for Payer: BCN Commercial |
$78.17
|
| Rate for Payer: BCN Commercial |
$66.66
|
| Rate for Payer: BCN Commercial |
$70.49
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$64.93
|
| Rate for Payer: Cash Price |
$68.67
|
| Rate for Payer: Cash Price |
$82.34
|
| Rate for Payer: Cofinity Commercial |
$80.69
|
| Rate for Payer: Cofinity Commercial |
$96.75
|
| Rate for Payer: Cofinity Commercial |
$89.47
|
| Rate for Payer: Cofinity Commercial |
$76.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.34
|
| Rate for Payer: Healthscope Commercial |
$83.27
|
| Rate for Payer: Healthscope Commercial |
$99.84
|
| Rate for Payer: Healthscope Commercial |
$78.73
|
| Rate for Payer: Healthscope Commercial |
$92.33
|
| Rate for Payer: Healthscope Whirlpool |
$85.84
|
| Rate for Payer: Healthscope Whirlpool |
$95.19
|
| Rate for Payer: Healthscope Whirlpool |
$102.93
|
| Rate for Payer: Healthscope Whirlpool |
$81.17
|
| Rate for Payer: Mclaren Commercial |
$92.64
|
| Rate for Payer: Mclaren Commercial |
$85.67
|
| Rate for Payer: Mclaren Commercial |
$73.05
|
| Rate for Payer: Mclaren Commercial |
$77.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.49
|
| Rate for Payer: Nomi Health Commercial |
$66.56
|
| Rate for Payer: Nomi Health Commercial |
$78.05
|
| Rate for Payer: Nomi Health Commercial |
$70.39
|
| Rate for Payer: Nomi Health Commercial |
$84.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$60.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$90.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$71.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.76
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION
|
Facility
|
IP
|
$132.34
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.25 |
| Max. Negotiated Rate |
$132.34 |
| Rate for Payer: Aetna Commercial |
$119.10
|
| Rate for Payer: Aetna Commercial |
$77.21
|
| Rate for Payer: Aetna Commercial |
$22.10
|
| Rate for Payer: ASR ASR |
$83.21
|
| Rate for Payer: ASR ASR |
$128.37
|
| Rate for Payer: ASR ASR |
$23.82
|
| Rate for Payer: BCBS Trust/PPO |
$70.45
|
| Rate for Payer: BCBS Trust/PPO |
$108.67
|
| Rate for Payer: BCBS Trust/PPO |
$20.17
|
| Rate for Payer: BCN Commercial |
$20.17
|
| Rate for Payer: BCN Commercial |
$108.67
|
| Rate for Payer: BCN Commercial |
$70.45
|
| Rate for Payer: Cash Price |
$68.63
|
| Rate for Payer: Cash Price |
$105.87
|
| Rate for Payer: Cash Price |
$19.65
|
| Rate for Payer: Cofinity Commercial |
$124.40
|
| Rate for Payer: Cofinity Commercial |
$23.08
|
| Rate for Payer: Cofinity Commercial |
$80.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.65
|
| Rate for Payer: Healthscope Commercial |
$23.82
|
| Rate for Payer: Healthscope Commercial |
$128.37
|
| Rate for Payer: Healthscope Commercial |
$83.21
|
| Rate for Payer: Healthscope Whirlpool |
$24.56
|
| Rate for Payer: Healthscope Whirlpool |
$85.78
|
| Rate for Payer: Healthscope Whirlpool |
$132.34
|
| Rate for Payer: Mclaren Commercial |
$22.10
|
| Rate for Payer: Mclaren Commercial |
$119.10
|
| Rate for Payer: Mclaren Commercial |
$77.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.49
|
| Rate for Payer: Nomi Health Commercial |
$20.14
|
| Rate for Payer: Nomi Health Commercial |
$108.52
|
| Rate for Payer: Nomi Health Commercial |
$70.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$99.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$116.46
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION
|
Facility
|
OP
|
$132.34
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.02 |
| Max. Negotiated Rate |
$132.34 |
| Rate for Payer: Aetna Commercial |
$119.10
|
| Rate for Payer: Aetna Commercial |
$22.10
|
| Rate for Payer: Aetna Commercial |
$77.21
|
| Rate for Payer: Aetna Medicare |
$9.09
|
| Rate for Payer: Aetna Medicare |
$48.96
|
| Rate for Payer: Aetna Medicare |
$31.74
|
| Rate for Payer: ASR ASR |
$83.21
|
| Rate for Payer: ASR ASR |
$128.37
|
| Rate for Payer: ASR ASR |
$23.82
|
| Rate for Payer: BCBS Complete |
$52.93
|
| Rate for Payer: BCBS Complete |
$34.31
|
| Rate for Payer: BCBS Complete |
$9.82
|
| Rate for Payer: BCBS Trust/PPO |
$109.11
|
| Rate for Payer: BCBS Trust/PPO |
$20.25
|
| Rate for Payer: BCBS Trust/PPO |
$70.73
|
| Rate for Payer: BCN Commercial |
$109.11
|
| Rate for Payer: BCN Commercial |
$20.25
|
| Rate for Payer: BCN Commercial |
$70.73
|
| Rate for Payer: Cash Price |
$19.65
|
| Rate for Payer: Cash Price |
$105.87
|
| Rate for Payer: Cash Price |
$19.65
|
| Rate for Payer: Cash Price |
$68.63
|
| Rate for Payer: Cash Price |
$68.63
|
| Rate for Payer: Cash Price |
$105.87
|
| Rate for Payer: Cofinity Commercial |
$23.08
|
| Rate for Payer: Cofinity Commercial |
$124.40
|
| Rate for Payer: Cofinity Commercial |
$80.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.65
|
| Rate for Payer: Healthscope Commercial |
$83.21
|
| Rate for Payer: Healthscope Commercial |
$128.37
|
| Rate for Payer: Healthscope Commercial |
$23.82
|
| Rate for Payer: Healthscope Whirlpool |
$24.56
|
| Rate for Payer: Healthscope Whirlpool |
$132.34
|
| Rate for Payer: Healthscope Whirlpool |
$85.78
|
| Rate for Payer: Mclaren Commercial |
$77.21
|
| Rate for Payer: Mclaren Commercial |
$22.10
|
| Rate for Payer: Mclaren Commercial |
$119.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.49
|
| Rate for Payer: Nomi Health Commercial |
$70.34
|
| Rate for Payer: Nomi Health Commercial |
$108.52
|
| Rate for Payer: Nomi Health Commercial |
$20.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$99.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.42
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.77
|
| Rate for Payer: Priority Health Narrow Network |
$7.02
|
| Rate for Payer: Priority Health Narrow Network |
$7.02
|
| Rate for Payer: Priority Health Narrow Network |
$7.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$116.46
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
OP
|
$75.60
|
|
|
Service Code
|
NDC 574052176
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.97 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Aetna Commercial |
$68.04
|
| Rate for Payer: Aetna Medicare |
$27.97
|
| Rate for Payer: ASR ASR |
$73.33
|
| Rate for Payer: BCBS Complete |
$30.24
|
| Rate for Payer: BCBS Trust/PPO |
$62.33
|
| Rate for Payer: BCN Commercial |
$62.33
|
| Rate for Payer: Cash Price |
$60.48
|
| Rate for Payer: Cofinity Commercial |
$71.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.48
|
| Rate for Payer: Healthscope Commercial |
$73.33
|
| Rate for Payer: Healthscope Whirlpool |
$75.60
|
| Rate for Payer: Mclaren Commercial |
$68.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$60.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$64.26
|
| Rate for Payer: Nomi Health Commercial |
$61.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.70
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$66.24
|
| Rate for Payer: Priority Health Narrow Network |
$53.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$66.53
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
OP
|
$85.68
|
|
|
Service Code
|
NDC 66689020208
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.70 |
| Max. Negotiated Rate |
$85.68 |
| Rate for Payer: Aetna Commercial |
$77.11
|
| Rate for Payer: Aetna Medicare |
$31.70
|
| Rate for Payer: ASR ASR |
$83.11
|
| Rate for Payer: BCBS Complete |
$34.27
|
| Rate for Payer: BCBS Trust/PPO |
$70.64
|
| Rate for Payer: BCN Commercial |
$70.64
|
| Rate for Payer: Cash Price |
$68.54
|
| Rate for Payer: Cofinity Commercial |
$80.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.54
|
| Rate for Payer: Healthscope Commercial |
$83.11
|
| Rate for Payer: Healthscope Whirlpool |
$85.68
|
| Rate for Payer: Mclaren Commercial |
$77.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.83
|
| Rate for Payer: Nomi Health Commercial |
$70.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.26
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$75.07
|
| Rate for Payer: Priority Health Narrow Network |
$60.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.40
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
OP
|
$97.44
|
|
|
Service Code
|
NDC 66689020108
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.05 |
| Max. Negotiated Rate |
$97.44 |
| Rate for Payer: Aetna Commercial |
$87.70
|
| Rate for Payer: Aetna Medicare |
$36.05
|
| Rate for Payer: ASR ASR |
$94.52
|
| Rate for Payer: BCBS Complete |
$38.98
|
| Rate for Payer: BCBS Trust/PPO |
$80.34
|
| Rate for Payer: BCN Commercial |
$80.34
|
| Rate for Payer: Cash Price |
$77.95
|
| Rate for Payer: Cofinity Commercial |
$91.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.95
|
| Rate for Payer: Healthscope Commercial |
$94.52
|
| Rate for Payer: Healthscope Whirlpool |
$97.44
|
| Rate for Payer: Mclaren Commercial |
$87.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$77.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.82
|
| Rate for Payer: Nomi Health Commercial |
$79.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$73.08
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$85.38
|
| Rate for Payer: Priority Health Narrow Network |
$68.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$85.75
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
IP
|
$75.60
|
|
|
Service Code
|
NDC 574052176
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Aetna Commercial |
$68.04
|
| Rate for Payer: ASR ASR |
$73.33
|
| Rate for Payer: BCBS Trust/PPO |
$62.08
|
| Rate for Payer: BCN Commercial |
$62.08
|
| Rate for Payer: Cash Price |
$60.48
|
| Rate for Payer: Cofinity Commercial |
$71.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.48
|
| Rate for Payer: Healthscope Commercial |
$73.33
|
| Rate for Payer: Healthscope Whirlpool |
$75.60
|
| Rate for Payer: Mclaren Commercial |
$68.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$64.26
|
| Rate for Payer: Nomi Health Commercial |
$61.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$66.53
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
IP
|
$85.68
|
|
|
Service Code
|
NDC 66689020208
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.26 |
| Max. Negotiated Rate |
$85.68 |
| Rate for Payer: Aetna Commercial |
$77.11
|
| Rate for Payer: ASR ASR |
$83.11
|
| Rate for Payer: BCBS Trust/PPO |
$70.36
|
| Rate for Payer: BCN Commercial |
$70.36
|
| Rate for Payer: Cash Price |
$68.54
|
| Rate for Payer: Cofinity Commercial |
$80.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.54
|
| Rate for Payer: Healthscope Commercial |
$83.11
|
| Rate for Payer: Healthscope Whirlpool |
$85.68
|
| Rate for Payer: Mclaren Commercial |
$77.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.83
|
| Rate for Payer: Nomi Health Commercial |
$70.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.40
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
IP
|
$97.44
|
|
|
Service Code
|
NDC 66689020108
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.08 |
| Max. Negotiated Rate |
$97.44 |
| Rate for Payer: Aetna Commercial |
$87.70
|
| Rate for Payer: ASR ASR |
$94.52
|
| Rate for Payer: BCBS Trust/PPO |
$80.02
|
| Rate for Payer: BCN Commercial |
$80.02
|
| Rate for Payer: Cash Price |
$77.95
|
| Rate for Payer: Cofinity Commercial |
$91.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.95
|
| Rate for Payer: Healthscope Commercial |
$94.52
|
| Rate for Payer: Healthscope Whirlpool |
$97.44
|
| Rate for Payer: Mclaren Commercial |
$87.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.82
|
| Rate for Payer: Nomi Health Commercial |
$79.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$73.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$85.75
|
|
|
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION
|
Facility
|
IP
|
$13,437.09
|
|
|
Service Code
|
MSDRG 880
|
| Min. Negotiated Rate |
$8,235.64 |
| Max. Negotiated Rate |
$13,437.09 |
| Rate for Payer: Aetna Medicare |
$8,669.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,836.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,836.36
|
| Rate for Payer: BCBS MAPPO |
$8,669.09
|
| Rate for Payer: BCN Medicare Advantage |
$8,669.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,669.09
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,669.09
|
| Rate for Payer: Mclaren Medicare |
$8,669.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9,102.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,969.45
|
| Rate for Payer: Molina Medicare/Medicaid |
$9,536.00
|
| Rate for Payer: PACE Medicare |
$8,235.64
|
| Rate for Payer: PACE SWMI |
$8,669.09
|
| Rate for Payer: PHP Commercial |
$9,536.00
|
| Rate for Payer: PHP Medicare Advantage |
$8,669.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$13,192.00
|
| Rate for Payer: Priority Health Medicare |
$8,669.09
|
| Rate for Payer: Priority Health Narrow Network |
$10,553.60
|
| Rate for Payer: Railroad Medicare Medicare |
$8,669.09
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,669.09
|
| Rate for Payer: UHC Exchange |
$13,437.09
|
| Rate for Payer: UHCCP DNSP |
$8,669.09
|
| Rate for Payer: VA VA |
$8,669.09
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$7,387.34
|
|
|
Service Code
|
APR-DRG 1932
|
| Min. Negotiated Rate |
$6,679.04 |
| Max. Negotiated Rate |
$7,387.34 |
| Rate for Payer: BCBS Complete |
$7,387.34
|
| Rate for Payer: Mclaren Medicaid |
$7,035.56
|
| Rate for Payer: Meridian Medicaid |
$7,387.34
|
| Rate for Payer: PHP Medicaid |
$6,679.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$7,035.56
|
| Rate for Payer: UHC Medicaid |
$7,035.56
|
| Rate for Payer: UHCCP Medicaid |
$7,035.56
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$6,494.17
|
|
|
Service Code
|
APR-DRG 1931
|
| Min. Negotiated Rate |
$5,871.51 |
| Max. Negotiated Rate |
$6,494.17 |
| Rate for Payer: BCBS Complete |
$6,494.17
|
| Rate for Payer: Mclaren Medicaid |
$6,184.92
|
| Rate for Payer: Meridian Medicaid |
$6,494.17
|
| Rate for Payer: PHP Medicaid |
$5,871.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,184.92
|
| Rate for Payer: UHC Medicaid |
$6,184.92
|
| Rate for Payer: UHCCP Medicaid |
$6,184.92
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$11,136.05
|
|
|
Service Code
|
APR-DRG 1933
|
| Min. Negotiated Rate |
$10,068.32 |
| Max. Negotiated Rate |
$11,136.05 |
| Rate for Payer: BCBS Complete |
$11,136.05
|
| Rate for Payer: Mclaren Medicaid |
$10,605.76
|
| Rate for Payer: Meridian Medicaid |
$11,136.05
|
| Rate for Payer: PHP Medicaid |
$10,068.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,605.76
|
| Rate for Payer: UHC Medicaid |
$10,605.76
|
| Rate for Payer: UHCCP Medicaid |
$10,605.76
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS
|
Facility
|
IP
|
$11,919.69
|
|
|
Service Code
|
APR-DRG 1934
|
| Min. Negotiated Rate |
$10,776.83 |
| Max. Negotiated Rate |
$11,919.69 |
| Rate for Payer: BCBS Complete |
$11,919.69
|
| Rate for Payer: Mclaren Medicaid |
$11,352.09
|
| Rate for Payer: Meridian Medicaid |
$11,919.69
|
| Rate for Payer: PHP Medicaid |
$10,776.83
|
| Rate for Payer: Priority Health Choice Medicaid |
$11,352.09
|
| Rate for Payer: UHC Medicaid |
$11,352.09
|
| Rate for Payer: UHCCP Medicaid |
$11,352.09
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC
|
Facility
|
IP
|
$23,450.76
|
|
|
Service Code
|
MSDRG 289
|
| Min. Negotiated Rate |
$13,343.96 |
| Max. Negotiated Rate |
$23,450.76 |
| Rate for Payer: Aetna Medicare |
$14,046.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,557.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,557.84
|
| Rate for Payer: BCBS MAPPO |
$14,046.27
|
| Rate for Payer: BCN Medicare Advantage |
$14,046.27
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,046.27
|
| Rate for Payer: Humana Choice PPO Medicare |
$14,046.27
|
| Rate for Payer: Mclaren Medicare |
$14,046.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14,748.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,153.21
|
| Rate for Payer: Molina Medicare/Medicaid |
$15,450.90
|
| Rate for Payer: PACE Medicare |
$13,343.96
|
| Rate for Payer: PACE SWMI |
$14,046.27
|
| Rate for Payer: PHP Commercial |
$15,450.90
|
| Rate for Payer: PHP Medicare Advantage |
$14,046.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23,450.76
|
| Rate for Payer: Priority Health Medicare |
$14,046.27
|
| Rate for Payer: Priority Health Narrow Network |
$18,760.61
|
| Rate for Payer: Railroad Medicare Medicare |
$14,046.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$14,046.27
|
| Rate for Payer: UHC Exchange |
$21,771.72
|
| Rate for Payer: UHCCP DNSP |
$14,046.27
|
| Rate for Payer: VA VA |
$14,046.27
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC
|
Facility
|
IP
|
$37,179.94
|
|
|
Service Code
|
MSDRG 288
|
| Min. Negotiated Rate |
$20,180.34 |
| Max. Negotiated Rate |
$37,179.94 |
| Rate for Payer: Aetna Medicare |
$21,242.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$26,553.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$26,553.08
|
| Rate for Payer: BCBS MAPPO |
$21,242.46
|
| Rate for Payer: BCN Medicare Advantage |
$21,242.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21,242.46
|
| Rate for Payer: Humana Choice PPO Medicare |
$21,242.46
|
| Rate for Payer: Mclaren Medicare |
$21,242.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$22,304.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24,428.83
|
| Rate for Payer: Molina Medicare/Medicaid |
$23,366.71
|
| Rate for Payer: PACE Medicare |
$20,180.34
|
| Rate for Payer: PACE SWMI |
$21,242.46
|
| Rate for Payer: PHP Commercial |
$23,366.71
|
| Rate for Payer: PHP Medicare Advantage |
$21,242.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$37,179.94
|
| Rate for Payer: Priority Health Medicare |
$21,242.46
|
| Rate for Payer: Priority Health Narrow Network |
$29,743.95
|
| Rate for Payer: Railroad Medicare Medicare |
$21,242.46
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$21,242.46
|
| Rate for Payer: UHC Exchange |
$32,925.81
|
| Rate for Payer: UHCCP DNSP |
$21,242.46
|
| Rate for Payer: VA VA |
$21,242.46
|
|
|
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$13,096.66
|
|
|
Service Code
|
MSDRG 290
|
| Min. Negotiated Rate |
$8,026.99 |
| Max. Negotiated Rate |
$13,096.66 |
| Rate for Payer: Aetna Medicare |
$8,449.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,561.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,561.83
|
| Rate for Payer: BCBS MAPPO |
$8,449.46
|
| Rate for Payer: BCN Medicare Advantage |
$8,449.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,449.46
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,449.46
|
| Rate for Payer: Mclaren Medicare |
$8,449.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,871.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,716.88
|
| Rate for Payer: Molina Medicare/Medicaid |
$9,294.41
|
| Rate for Payer: PACE Medicare |
$8,026.99
|
| Rate for Payer: PACE SWMI |
$8,449.46
|
| Rate for Payer: PHP Commercial |
$9,294.41
|
| Rate for Payer: PHP Medicare Advantage |
$8,449.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$12,772.96
|
| Rate for Payer: Priority Health Medicare |
$8,449.46
|
| Rate for Payer: Priority Health Narrow Network |
$10,218.37
|
| Rate for Payer: Railroad Medicare Medicare |
$8,449.46
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,449.46
|
| Rate for Payer: UHC Exchange |
$13,096.66
|
| Rate for Payer: UHCCP DNSP |
$8,449.46
|
| Rate for Payer: VA VA |
$8,449.46
|
|
|
ACUTE ANXIETY AND STRESS SYNDROMES
|
Facility
|
IP
|
$12,766.00
|
|
|
Service Code
|
APR-DRG 7564
|
| Min. Negotiated Rate |
$11,541.99 |
| Max. Negotiated Rate |
$12,766.00 |
| Rate for Payer: BCBS Complete |
$12,766.00
|
| Rate for Payer: Mclaren Medicaid |
$12,158.09
|
| Rate for Payer: Meridian Medicaid |
$12,766.00
|
| Rate for Payer: PHP Medicaid |
$11,541.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$12,158.09
|
| Rate for Payer: UHC Medicaid |
$12,158.09
|
| Rate for Payer: UHCCP Medicaid |
$12,158.09
|
|
|
ACUTE ANXIETY AND STRESS SYNDROMES
|
Facility
|
IP
|
$3,088.23
|
|
|
Service Code
|
APR-DRG 7561
|
| Min. Negotiated Rate |
$2,792.13 |
| Max. Negotiated Rate |
$3,088.23 |
| Rate for Payer: BCBS Complete |
$3,088.23
|
| Rate for Payer: Mclaren Medicaid |
$2,941.17
|
| Rate for Payer: Meridian Medicaid |
$3,088.23
|
| Rate for Payer: PHP Medicaid |
$2,792.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,941.17
|
| Rate for Payer: UHC Medicaid |
$2,941.17
|
| Rate for Payer: UHCCP Medicaid |
$2,941.17
|
|
