|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$63.80
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.66 |
| Max. Negotiated Rate |
$63.80 |
| Rate for Payer: Aetna Commercial |
$57.42
|
| Rate for Payer: Aetna Commercial |
$46.66
|
| Rate for Payer: Aetna Commercial |
$60.46
|
| Rate for Payer: Aetna Commercial |
$50.39
|
| Rate for Payer: ASR ASR |
$61.89
|
| Rate for Payer: ASR ASR |
$50.28
|
| Rate for Payer: ASR ASR |
$54.31
|
| Rate for Payer: ASR ASR |
$65.16
|
| Rate for Payer: BCBS Trust/PPO |
$49.46
|
| Rate for Payer: BCBS Trust/PPO |
$43.41
|
| Rate for Payer: BCBS Trust/PPO |
$52.08
|
| Rate for Payer: BCBS Trust/PPO |
$40.19
|
| Rate for Payer: BCN Commercial |
$52.08
|
| Rate for Payer: BCN Commercial |
$40.19
|
| Rate for Payer: BCN Commercial |
$43.41
|
| Rate for Payer: BCN Commercial |
$49.46
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cash Price |
$41.47
|
| Rate for Payer: Cofinity Commercial |
$48.73
|
| Rate for Payer: Cofinity Commercial |
$59.97
|
| Rate for Payer: Cofinity Commercial |
$52.63
|
| Rate for Payer: Cofinity Commercial |
$63.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Healthscope Commercial |
$51.84
|
| Rate for Payer: Healthscope Commercial |
$55.99
|
| Rate for Payer: Healthscope Commercial |
$67.18
|
| Rate for Payer: Healthscope Commercial |
$63.80
|
| Rate for Payer: Healthscope Whirlpool |
$50.28
|
| Rate for Payer: Healthscope Whirlpool |
$54.31
|
| Rate for Payer: Healthscope Whirlpool |
$61.89
|
| Rate for Payer: Healthscope Whirlpool |
$65.16
|
| Rate for Payer: Mclaren Commercial |
$50.39
|
| Rate for Payer: Mclaren Commercial |
$57.42
|
| Rate for Payer: Mclaren Commercial |
$60.46
|
| Rate for Payer: Mclaren Commercial |
$46.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.14
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.94 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$62.93
|
| Rate for Payer: ASR ASR |
$67.82
|
| Rate for Payer: BCBS Trust/PPO |
$54.21
|
| Rate for Payer: BCN Commercial |
$54.21
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$65.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$69.92
|
| Rate for Payer: Healthscope Whirlpool |
$67.82
|
| Rate for Payer: Mclaren Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.53
|
|
|
DIABETES WITH CC
|
Facility
|
IP
|
$11,619.51
|
|
|
Service Code
|
MS-DRG 638
|
| Min. Negotiated Rate |
$8,830.83 |
| Max. Negotiated Rate |
$11,619.51 |
| Rate for Payer: Aetna Medicare |
$9,295.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,619.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,619.51
|
| Rate for Payer: BCBS MAPPO |
$9,295.61
|
| Rate for Payer: BCN Medicare Advantage |
$9,295.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,295.61
|
| Rate for Payer: Humana Choice PPO Medicare |
$9,295.61
|
| Rate for Payer: Mclaren Medicare |
$9,295.61
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,760.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,689.95
|
| Rate for Payer: PACE Medicare |
$8,830.83
|
| Rate for Payer: PACE SWMI |
$9,295.61
|
| Rate for Payer: PHP Commercial |
$10,225.17
|
| Rate for Payer: PHP Medicare Advantage |
$9,295.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,548.30
|
| Rate for Payer: Priority Health Medicare |
$9,295.61
|
| Rate for Payer: Priority Health Narrow Network |
$9,238.64
|
| Rate for Payer: Railroad Medicare Medicare |
$9,295.61
|
| Rate for Payer: UHC Medicare Advantage |
$9,574.48
|
| Rate for Payer: VA VA |
$9,295.61
|
|
|
DIABETES WITH MCC
|
Facility
|
IP
|
$18,609.01
|
|
|
Service Code
|
MS-DRG 637
|
| Min. Negotiated Rate |
$13,253.73 |
| Max. Negotiated Rate |
$18,609.01 |
| Rate for Payer: Aetna Medicare |
$13,951.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,439.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,439.11
|
| Rate for Payer: BCBS MAPPO |
$13,951.29
|
| Rate for Payer: BCN Medicare Advantage |
$13,951.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,951.29
|
| Rate for Payer: Humana Choice PPO Medicare |
$13,951.29
|
| Rate for Payer: Mclaren Medicare |
$13,951.29
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,648.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,043.98
|
| Rate for Payer: PACE Medicare |
$13,253.73
|
| Rate for Payer: PACE SWMI |
$13,951.29
|
| Rate for Payer: PHP Commercial |
$15,346.42
|
| Rate for Payer: PHP Medicare Advantage |
$13,951.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,609.01
|
| Rate for Payer: Priority Health Medicare |
$13,951.29
|
| Rate for Payer: Priority Health Narrow Network |
$14,887.21
|
| Rate for Payer: Railroad Medicare Medicare |
$13,951.29
|
| Rate for Payer: UHC Medicare Advantage |
$14,369.83
|
| Rate for Payer: VA VA |
$13,951.29
|
|
|
DIABETES WITHOUT CC/MCC
|
Facility
|
IP
|
$8,689.10
|
|
|
Service Code
|
MS-DRG 639
|
| Min. Negotiated Rate |
$6,394.32 |
| Max. Negotiated Rate |
$8,689.10 |
| Rate for Payer: Aetna Medicare |
$6,951.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,689.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,689.10
|
| Rate for Payer: BCBS MAPPO |
$6,951.28
|
| Rate for Payer: BCN Medicare Advantage |
$6,951.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,951.28
|
| Rate for Payer: Humana Choice PPO Medicare |
$6,951.28
|
| Rate for Payer: Mclaren Medicare |
$6,951.28
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,298.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,993.97
|
| Rate for Payer: PACE Medicare |
$6,603.72
|
| Rate for Payer: PACE SWMI |
$6,951.28
|
| Rate for Payer: PHP Commercial |
$7,646.41
|
| Rate for Payer: PHP Medicare Advantage |
$6,951.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7,992.90
|
| Rate for Payer: Priority Health Medicare |
$6,951.28
|
| Rate for Payer: Priority Health Narrow Network |
$6,394.32
|
| Rate for Payer: Railroad Medicare Medicare |
$6,951.28
|
| Rate for Payer: UHC Medicare Advantage |
$7,159.82
|
| Rate for Payer: VA VA |
$6,951.28
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION
|
Facility
|
IP
|
$79.20
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
27735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.44 |
| Max. Negotiated Rate |
$79.20 |
| Rate for Payer: Aetna Commercial |
$71.28
|
| Rate for Payer: ASR ASR |
$76.82
|
| Rate for Payer: BCBS Trust/PPO |
$61.40
|
| Rate for Payer: BCN Commercial |
$61.40
|
| Rate for Payer: Cash Price |
$63.36
|
| Rate for Payer: Cofinity Commercial |
$74.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.36
|
| Rate for Payer: Healthscope Commercial |
$79.20
|
| Rate for Payer: Healthscope Whirlpool |
$76.82
|
| Rate for Payer: Mclaren Commercial |
$71.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$69.70
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION
|
Facility
|
IP
|
$63.72
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.60 |
| Max. Negotiated Rate |
$63.72 |
| Rate for Payer: Aetna Commercial |
$57.35
|
| Rate for Payer: ASR ASR |
$61.81
|
| Rate for Payer: BCBS Trust/PPO |
$49.40
|
| Rate for Payer: BCN Commercial |
$49.40
|
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: Cofinity Commercial |
$59.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.98
|
| Rate for Payer: Healthscope Commercial |
$63.72
|
| Rate for Payer: Healthscope Whirlpool |
$61.81
|
| Rate for Payer: Mclaren Commercial |
$57.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.07
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 51079-284-20
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.06 |
| Max. Negotiated Rate |
$138.65 |
| Rate for Payer: Aetna Commercial |
$124.78
|
| Rate for Payer: ASR ASR |
$134.49
|
| Rate for Payer: BCBS Trust/PPO |
$107.50
|
| Rate for Payer: BCN Commercial |
$107.50
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$130.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$138.65
|
| Rate for Payer: Healthscope Whirlpool |
$134.49
|
| Rate for Payer: Mclaren Commercial |
$124.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$122.01
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 51079-284-01
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna Commercial |
$1.25
|
| Rate for Payer: ASR ASR |
$1.35
|
| Rate for Payer: BCBS Trust/PPO |
$1.08
|
| Rate for Payer: BCN Commercial |
$1.08
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cofinity Commercial |
$1.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.11
|
| Rate for Payer: Healthscope Commercial |
$1.39
|
| Rate for Payer: Healthscope Whirlpool |
$1.35
|
| Rate for Payer: Mclaren Commercial |
$1.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.22
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
NDC 51079-285-20
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.48 |
| Max. Negotiated Rate |
$129.25 |
| Rate for Payer: Aetna Commercial |
$116.32
|
| Rate for Payer: ASR ASR |
$125.37
|
| Rate for Payer: BCBS Trust/PPO |
$100.21
|
| Rate for Payer: BCN Commercial |
$100.21
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Commercial |
$121.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$129.25
|
| Rate for Payer: Healthscope Whirlpool |
$125.37
|
| Rate for Payer: Mclaren Commercial |
$116.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$113.74
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 63739-073-10
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.09 |
| Max. Negotiated Rate |
$98.70 |
| Rate for Payer: Aetna Commercial |
$88.83
|
| Rate for Payer: ASR ASR |
$95.74
|
| Rate for Payer: BCBS Trust/PPO |
$76.52
|
| Rate for Payer: BCN Commercial |
$76.52
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$92.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$98.70
|
| Rate for Payer: Healthscope Whirlpool |
$95.74
|
| Rate for Payer: Mclaren Commercial |
$88.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$86.86
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
NDC 51079-285-01
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: ASR ASR |
$1.25
|
| Rate for Payer: BCBS Trust/PPO |
$1.00
|
| Rate for Payer: BCN Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cofinity Commercial |
$1.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.03
|
| Rate for Payer: Healthscope Commercial |
$1.29
|
| Rate for Payer: Healthscope Whirlpool |
$1.25
|
| Rate for Payer: Mclaren Commercial |
$1.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.14
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$21.66
|
|
|
Service Code
|
NDC 45802-050-03
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$21.66 |
| Rate for Payer: Aetna Commercial |
$19.49
|
| Rate for Payer: ASR ASR |
$21.01
|
| Rate for Payer: BCBS Trust/PPO |
$16.79
|
| Rate for Payer: BCN Commercial |
$16.79
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$21.66
|
| Rate for Payer: Healthscope Whirlpool |
$21.01
|
| Rate for Payer: Mclaren Commercial |
$19.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.06
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$34.20
|
|
|
Service Code
|
NDC 61314-014-25
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.94 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna Commercial |
$30.78
|
| Rate for Payer: ASR ASR |
$33.17
|
| Rate for Payer: BCBS Trust/PPO |
$26.52
|
| Rate for Payer: BCN Commercial |
$26.52
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$32.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.36
|
| Rate for Payer: Healthscope Commercial |
$34.20
|
| Rate for Payer: Healthscope Whirlpool |
$33.17
|
| Rate for Payer: Mclaren Commercial |
$30.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.10
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$23.22
|
|
|
Service Code
|
NDC 17478-892-10
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.25 |
| Max. Negotiated Rate |
$23.22 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: ASR ASR |
$22.52
|
| Rate for Payer: BCBS Trust/PPO |
$18.00
|
| Rate for Payer: BCN Commercial |
$18.00
|
| Rate for Payer: Cash Price |
$18.58
|
| Rate for Payer: Cofinity Commercial |
$21.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.58
|
| Rate for Payer: Healthscope Commercial |
$23.22
|
| Rate for Payer: Healthscope Whirlpool |
$22.52
|
| Rate for Payer: Mclaren Commercial |
$20.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.43
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$22.86
|
|
|
Service Code
|
NDC 24208-457-05
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$22.86 |
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: ASR ASR |
$22.17
|
| Rate for Payer: BCBS Trust/PPO |
$17.72
|
| Rate for Payer: BCN Commercial |
$17.72
|
| Rate for Payer: Cash Price |
$18.28
|
| Rate for Payer: Cofinity Commercial |
$21.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.29
|
| Rate for Payer: Healthscope Commercial |
$22.86
|
| Rate for Payer: Healthscope Whirlpool |
$22.17
|
| Rate for Payer: Mclaren Commercial |
$20.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.12
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 96295-13974
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$20.25 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.70
|
| Rate for Payer: BCN Commercial |
$15.70
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$19.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$20.25
|
| Rate for Payer: Healthscope Whirlpool |
$19.64
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.82
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$39.73
|
|
|
Service Code
|
NDC 0067-8152-02
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.81 |
| Max. Negotiated Rate |
$39.73 |
| Rate for Payer: Aetna Commercial |
$35.76
|
| Rate for Payer: ASR ASR |
$38.54
|
| Rate for Payer: BCBS Trust/PPO |
$30.80
|
| Rate for Payer: BCN Commercial |
$30.80
|
| Rate for Payer: Cash Price |
$31.78
|
| Rate for Payer: Cofinity Commercial |
$37.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.78
|
| Rate for Payer: Healthscope Commercial |
$39.73
|
| Rate for Payer: Healthscope Whirlpool |
$38.54
|
| Rate for Payer: Mclaren Commercial |
$35.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$34.96
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$23.98
|
|
|
Service Code
|
NDC 0536-1294-34
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.79 |
| Max. Negotiated Rate |
$23.98 |
| Rate for Payer: Aetna Commercial |
$21.58
|
| Rate for Payer: ASR ASR |
$23.26
|
| Rate for Payer: BCBS Trust/PPO |
$18.59
|
| Rate for Payer: BCN Commercial |
$18.59
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cofinity Commercial |
$22.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.18
|
| Rate for Payer: Healthscope Commercial |
$23.98
|
| Rate for Payer: Healthscope Whirlpool |
$23.26
|
| Rate for Payer: Mclaren Commercial |
$21.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.10
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079-118-01
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: ASR ASR |
$3.71
|
| Rate for Payer: BCBS Trust/PPO |
$2.96
|
| Rate for Payer: BCN Commercial |
$2.96
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.82
|
| Rate for Payer: Healthscope Whirlpool |
$3.71
|
| Rate for Payer: Mclaren Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.36
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 0591-0794-01
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$305.97 |
| Max. Negotiated Rate |
$437.10 |
| Rate for Payer: Aetna Commercial |
$393.39
|
| Rate for Payer: ASR ASR |
$423.99
|
| Rate for Payer: BCBS Trust/PPO |
$338.88
|
| Rate for Payer: BCN Commercial |
$338.88
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$410.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$437.10
|
| Rate for Payer: Healthscope Whirlpool |
$423.99
|
| Rate for Payer: Mclaren Commercial |
$393.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$384.65
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$388.55
|
|
|
Service Code
|
NDC 0904-6987-61
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.98 |
| Max. Negotiated Rate |
$388.55 |
| Rate for Payer: Aetna Commercial |
$349.70
|
| Rate for Payer: ASR ASR |
$376.89
|
| Rate for Payer: BCBS Trust/PPO |
$301.24
|
| Rate for Payer: BCN Commercial |
$301.24
|
| Rate for Payer: Cash Price |
$310.84
|
| Rate for Payer: Cofinity Commercial |
$365.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.84
|
| Rate for Payer: Healthscope Commercial |
$388.55
|
| Rate for Payer: Healthscope Whirlpool |
$376.89
|
| Rate for Payer: Mclaren Commercial |
$349.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$330.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$341.92
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$161.40
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.98 |
| Max. Negotiated Rate |
$161.40 |
| Rate for Payer: Aetna Commercial |
$145.26
|
| Rate for Payer: Aetna Commercial |
$29.23
|
| Rate for Payer: Aetna Commercial |
$29.80
|
| Rate for Payer: Aetna Commercial |
$249.77
|
| Rate for Payer: Aetna Commercial |
$64.02
|
| Rate for Payer: Aetna Commercial |
$156.19
|
| Rate for Payer: ASR ASR |
$69.00
|
| Rate for Payer: ASR ASR |
$156.56
|
| Rate for Payer: ASR ASR |
$168.33
|
| Rate for Payer: ASR ASR |
$31.51
|
| Rate for Payer: ASR ASR |
$32.12
|
| Rate for Payer: ASR ASR |
$269.19
|
| Rate for Payer: BCBS Trust/PPO |
$55.15
|
| Rate for Payer: BCBS Trust/PPO |
$25.18
|
| Rate for Payer: BCBS Trust/PPO |
$134.55
|
| Rate for Payer: BCBS Trust/PPO |
$125.13
|
| Rate for Payer: BCBS Trust/PPO |
$25.67
|
| Rate for Payer: BCBS Trust/PPO |
$215.16
|
| Rate for Payer: BCN Commercial |
$55.15
|
| Rate for Payer: BCN Commercial |
$215.16
|
| Rate for Payer: BCN Commercial |
$125.13
|
| Rate for Payer: BCN Commercial |
$134.55
|
| Rate for Payer: BCN Commercial |
$25.18
|
| Rate for Payer: BCN Commercial |
$25.67
|
| Rate for Payer: Cash Price |
$138.83
|
| Rate for Payer: Cash Price |
$56.90
|
| Rate for Payer: Cash Price |
$129.12
|
| Rate for Payer: Cash Price |
$26.49
|
| Rate for Payer: Cash Price |
$25.99
|
| Rate for Payer: Cash Price |
$222.01
|
| Rate for Payer: Cofinity Commercial |
$163.13
|
| Rate for Payer: Cofinity Commercial |
$151.72
|
| Rate for Payer: Cofinity Commercial |
$260.87
|
| Rate for Payer: Cofinity Commercial |
$66.86
|
| Rate for Payer: Cofinity Commercial |
$31.12
|
| Rate for Payer: Cofinity Commercial |
$30.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.49
|
| Rate for Payer: Healthscope Commercial |
$33.11
|
| Rate for Payer: Healthscope Commercial |
$173.54
|
| Rate for Payer: Healthscope Commercial |
$32.48
|
| Rate for Payer: Healthscope Commercial |
$71.13
|
| Rate for Payer: Healthscope Commercial |
$277.52
|
| Rate for Payer: Healthscope Commercial |
$161.40
|
| Rate for Payer: Healthscope Whirlpool |
$31.51
|
| Rate for Payer: Healthscope Whirlpool |
$69.00
|
| Rate for Payer: Healthscope Whirlpool |
$168.33
|
| Rate for Payer: Healthscope Whirlpool |
$32.12
|
| Rate for Payer: Healthscope Whirlpool |
$156.56
|
| Rate for Payer: Healthscope Whirlpool |
$269.19
|
| Rate for Payer: Mclaren Commercial |
$156.19
|
| Rate for Payer: Mclaren Commercial |
$249.77
|
| Rate for Payer: Mclaren Commercial |
$29.80
|
| Rate for Payer: Mclaren Commercial |
$64.02
|
| Rate for Payer: Mclaren Commercial |
$145.26
|
| Rate for Payer: Mclaren Commercial |
$29.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$152.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.14
|
|
|
DIGESTIVE MALIGNANCY WITH CC
|
Facility
|
IP
|
$15,386.17
|
|
|
Service Code
|
MS-DRG 375
|
| Min. Negotiated Rate |
$11,234.92 |
| Max. Negotiated Rate |
$15,386.17 |
| Rate for Payer: Aetna Medicare |
$11,826.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,782.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,782.79
|
| Rate for Payer: BCBS MAPPO |
$11,826.23
|
| Rate for Payer: BCN Medicare Advantage |
$11,826.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,826.23
|
| Rate for Payer: Humana Choice PPO Medicare |
$11,826.23
|
| Rate for Payer: Mclaren Medicare |
$11,826.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,417.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,600.16
|
| Rate for Payer: PACE Medicare |
$11,234.92
|
| Rate for Payer: PACE SWMI |
$11,826.23
|
| Rate for Payer: PHP Commercial |
$13,008.85
|
| Rate for Payer: PHP Medicare Advantage |
$11,826.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,386.17
|
| Rate for Payer: Priority Health Medicare |
$11,826.23
|
| Rate for Payer: Priority Health Narrow Network |
$12,308.94
|
| Rate for Payer: Railroad Medicare Medicare |
$11,826.23
|
| Rate for Payer: UHC Medicare Advantage |
$12,181.02
|
| Rate for Payer: VA VA |
$11,826.23
|
|
|
DIGESTIVE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$26,951.16
|
|
|
Service Code
|
MS-DRG 374
|
| Min. Negotiated Rate |
$18,479.30 |
| Max. Negotiated Rate |
$26,951.16 |
| Rate for Payer: Aetna Medicare |
$19,451.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,314.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,314.88
|
| Rate for Payer: BCBS MAPPO |
$19,451.90
|
| Rate for Payer: BCN Medicare Advantage |
$19,451.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,451.90
|
| Rate for Payer: Humana Choice PPO Medicare |
$19,451.90
|
| Rate for Payer: Mclaren Medicare |
$19,451.90
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$20,424.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,369.68
|
| Rate for Payer: PACE Medicare |
$18,479.30
|
| Rate for Payer: PACE SWMI |
$19,451.90
|
| Rate for Payer: PHP Commercial |
$21,397.09
|
| Rate for Payer: PHP Medicare Advantage |
$19,451.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26,951.16
|
| Rate for Payer: Priority Health Medicare |
$19,451.90
|
| Rate for Payer: Priority Health Narrow Network |
$21,560.93
|
| Rate for Payer: Railroad Medicare Medicare |
$19,451.90
|
| Rate for Payer: UHC Medicare Advantage |
$20,035.46
|
| Rate for Payer: VA VA |
$19,451.90
|
|
