|
EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE
|
Facility
|
IP
|
$77,041.28
|
|
|
Service Code
|
MS-DRG 790
|
| Min. Negotiated Rate |
$49,856.15 |
| Max. Negotiated Rate |
$77,041.28 |
| Rate for Payer: Aetna Medicare |
$52,480.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$65,600.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$65,600.20
|
| Rate for Payer: BCBS MAPPO |
$52,480.16
|
| Rate for Payer: BCN Medicare Advantage |
$52,480.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$52,480.16
|
| Rate for Payer: Humana Choice PPO Medicare |
$52,480.16
|
| Rate for Payer: Mclaren Medicare |
$52,480.16
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$55,104.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$60,352.18
|
| Rate for Payer: PACE Medicare |
$49,856.15
|
| Rate for Payer: PACE SWMI |
$52,480.16
|
| Rate for Payer: PHP Commercial |
$57,728.18
|
| Rate for Payer: PHP Medicare Advantage |
$52,480.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$77,041.28
|
| Rate for Payer: Priority Health Medicare |
$52,480.16
|
| Rate for Payer: Priority Health Narrow Network |
$61,633.02
|
| Rate for Payer: Railroad Medicare Medicare |
$52,480.16
|
| Rate for Payer: UHC Medicare Advantage |
$54,054.56
|
| Rate for Payer: VA VA |
$52,480.16
|
|
|
EYELASH TINTING
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 00176
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: BCBS Complete |
$12.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.00
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$66.27
|
|
|
Service Code
|
NDC 67877-490-30
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.39 |
| Max. Negotiated Rate |
$66.27 |
| Rate for Payer: Aetna Commercial |
$59.64
|
| Rate for Payer: ASR ASR |
$64.28
|
| Rate for Payer: BCBS Trust/PPO |
$51.38
|
| Rate for Payer: BCN Commercial |
$51.38
|
| Rate for Payer: Cash Price |
$53.02
|
| Rate for Payer: Cofinity Commercial |
$62.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.02
|
| Rate for Payer: Healthscope Commercial |
$66.27
|
| Rate for Payer: Healthscope Whirlpool |
$64.28
|
| Rate for Payer: Mclaren Commercial |
$59.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$58.32
|
|
|
FACIAL
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 00174
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: BCBS Complete |
$26.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$152.75
|
|
|
Service Code
|
NDC 0904-7193-61
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.92 |
| Max. Negotiated Rate |
$152.75 |
| Rate for Payer: Aetna Commercial |
$137.48
|
| Rate for Payer: ASR ASR |
$148.17
|
| Rate for Payer: BCBS Trust/PPO |
$118.43
|
| Rate for Payer: BCN Commercial |
$118.43
|
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Cofinity Commercial |
$143.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.20
|
| Rate for Payer: Healthscope Commercial |
$152.75
|
| Rate for Payer: Healthscope Whirlpool |
$148.17
|
| Rate for Payer: Mclaren Commercial |
$137.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$129.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.42
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079-966-20
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.64 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.24
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: BCBS Trust/PPO |
$114.78
|
| Rate for Payer: BCN Commercial |
$114.78
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.61
|
| Rate for Payer: Mclaren Commercial |
$133.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.28
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 51079-966-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: ASR ASR |
$1.44
|
| Rate for Payer: BCBS Trust/PPO |
$1.15
|
| Rate for Payer: BCN Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.18
|
| Rate for Payer: Healthscope Commercial |
$1.48
|
| Rate for Payer: Healthscope Whirlpool |
$1.44
|
| Rate for Payer: Mclaren Commercial |
$1.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.30
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
|
Service Code
|
NDC 61442-121-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.28 |
| Max. Negotiated Rate |
$150.40 |
| Rate for Payer: Aetna Commercial |
$135.36
|
| Rate for Payer: ASR ASR |
$145.89
|
| Rate for Payer: BCBS Trust/PPO |
$116.61
|
| Rate for Payer: BCN Commercial |
$116.61
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$141.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$150.40
|
| Rate for Payer: Healthscope Whirlpool |
$145.89
|
| Rate for Payer: Mclaren Commercial |
$135.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$132.35
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$190.35
|
|
|
Service Code
|
NDC 0536-1298-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.24 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna Commercial |
$171.32
|
| Rate for Payer: ASR ASR |
$184.64
|
| Rate for Payer: BCBS Trust/PPO |
$147.58
|
| Rate for Payer: BCN Commercial |
$147.58
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$178.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Healthscope Whirlpool |
$184.64
|
| Rate for Payer: Mclaren Commercial |
$171.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$167.51
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.21
|
|
|
Service Code
|
NDC 0641-6022-01
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Aetna Commercial |
$10.99
|
| Rate for Payer: ASR ASR |
$11.84
|
| Rate for Payer: BCBS Trust/PPO |
$9.47
|
| Rate for Payer: BCN Commercial |
$9.47
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cofinity Commercial |
$11.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.77
|
| Rate for Payer: Healthscope Commercial |
$12.21
|
| Rate for Payer: Healthscope Whirlpool |
$11.84
|
| Rate for Payer: Mclaren Commercial |
$10.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.74
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.01
|
|
|
Service Code
|
NDC 67457-433-00
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$12.01 |
| Rate for Payer: Aetna Commercial |
$10.81
|
| Rate for Payer: ASR ASR |
$11.65
|
| Rate for Payer: BCBS Trust/PPO |
$9.31
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$11.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.61
|
| Rate for Payer: Healthscope Commercial |
$12.01
|
| Rate for Payer: Healthscope Whirlpool |
$11.65
|
| Rate for Payer: Mclaren Commercial |
$10.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.57
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 70860-751-41
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$13.50
|
| Rate for Payer: ASR ASR |
$14.55
|
| Rate for Payer: BCBS Trust/PPO |
$11.63
|
| Rate for Payer: BCN Commercial |
$11.63
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$15.00
|
| Rate for Payer: Healthscope Whirlpool |
$14.55
|
| Rate for Payer: Mclaren Commercial |
$13.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.20
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.01
|
|
|
Service Code
|
NDC 67457-433-22
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$12.01 |
| Rate for Payer: Aetna Commercial |
$10.81
|
| Rate for Payer: ASR ASR |
$11.65
|
| Rate for Payer: BCBS Trust/PPO |
$9.31
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$11.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.61
|
| Rate for Payer: Healthscope Commercial |
$12.01
|
| Rate for Payer: Healthscope Whirlpool |
$11.65
|
| Rate for Payer: Mclaren Commercial |
$10.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.57
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 70860-751-02
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$13.50
|
| Rate for Payer: ASR ASR |
$14.55
|
| Rate for Payer: BCBS Trust/PPO |
$11.63
|
| Rate for Payer: BCN Commercial |
$11.63
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$15.00
|
| Rate for Payer: Healthscope Whirlpool |
$14.55
|
| Rate for Payer: Mclaren Commercial |
$13.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.20
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
NDC 63323-739-12
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.24 |
| Max. Negotiated Rate |
$16.05 |
| Rate for Payer: Aetna Commercial |
$14.44
|
| Rate for Payer: ASR ASR |
$15.57
|
| Rate for Payer: BCBS Trust/PPO |
$12.44
|
| Rate for Payer: BCN Commercial |
$12.44
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$15.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$16.05
|
| Rate for Payer: Healthscope Whirlpool |
$15.57
|
| Rate for Payer: Mclaren Commercial |
$14.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.12
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
NDC 0338-0519-13
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: ASR ASR |
$194.00
|
| Rate for Payer: BCBS Trust/PPO |
$155.06
|
| Rate for Payer: BCN Commercial |
$155.06
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cofinity Commercial |
$188.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.00
|
| Rate for Payer: Healthscope Commercial |
$200.00
|
| Rate for Payer: Healthscope Whirlpool |
$194.00
|
| Rate for Payer: Mclaren Commercial |
$180.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.00
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 0338-0519-58
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.65 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: ASR ASR |
$9.22
|
| Rate for Payer: BCBS Trust/PPO |
$7.37
|
| Rate for Payer: BCN Commercial |
$7.37
|
| Rate for Payer: Cash Price |
$7.60
|
| Rate for Payer: Cofinity Commercial |
$8.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.60
|
| Rate for Payer: Healthscope Commercial |
$9.50
|
| Rate for Payer: Healthscope Whirlpool |
$9.22
|
| Rate for Payer: Mclaren Commercial |
$8.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.36
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 0338-9540-03
|
| Hospital Charge Code |
191280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$11.70
|
| Rate for Payer: ASR ASR |
$12.61
|
| Rate for Payer: BCBS Trust/PPO |
$10.08
|
| Rate for Payer: BCN Commercial |
$10.08
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cofinity Commercial |
$12.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.40
|
| Rate for Payer: Healthscope Commercial |
$13.00
|
| Rate for Payer: Healthscope Whirlpool |
$12.61
|
| Rate for Payer: Mclaren Commercial |
$11.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.44
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS
|
Facility
|
IP
|
$22.50
|
|
|
Service Code
|
NDC 63323-820-74
|
| Hospital Charge Code |
179808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Aetna Commercial |
$20.25
|
| Rate for Payer: ASR ASR |
$21.82
|
| Rate for Payer: BCBS Trust/PPO |
$17.44
|
| Rate for Payer: BCN Commercial |
$17.44
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cofinity Commercial |
$21.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.00
|
| Rate for Payer: Healthscope Commercial |
$22.50
|
| Rate for Payer: Healthscope Whirlpool |
$21.82
|
| Rate for Payer: Mclaren Commercial |
$20.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.80
|
|
|
FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$432.40
|
|
|
Service Code
|
NDC 13668-132-01
|
| Hospital Charge Code |
27489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$302.68 |
| Max. Negotiated Rate |
$432.40 |
| Rate for Payer: Aetna Commercial |
$389.16
|
| Rate for Payer: ASR ASR |
$419.43
|
| Rate for Payer: BCBS Trust/PPO |
$335.24
|
| Rate for Payer: BCN Commercial |
$335.24
|
| Rate for Payer: Cash Price |
$345.92
|
| Rate for Payer: Cofinity Commercial |
$406.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$345.92
|
| Rate for Payer: Healthscope Commercial |
$432.40
|
| Rate for Payer: Healthscope Whirlpool |
$419.43
|
| Rate for Payer: Mclaren Commercial |
$389.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$367.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$302.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$380.51
|
|
|
FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$267.84
|
|
|
Service Code
|
NDC 0603-3581-21
|
| Hospital Charge Code |
27489
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.49 |
| Max. Negotiated Rate |
$267.84 |
| Rate for Payer: Aetna Commercial |
$241.06
|
| Rate for Payer: ASR ASR |
$259.80
|
| Rate for Payer: BCBS Trust/PPO |
$207.66
|
| Rate for Payer: BCN Commercial |
$207.66
|
| Rate for Payer: Cash Price |
$214.27
|
| Rate for Payer: Cofinity Commercial |
$251.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.27
|
| Rate for Payer: Healthscope Commercial |
$267.84
|
| Rate for Payer: Healthscope Whirlpool |
$259.80
|
| Rate for Payer: Mclaren Commercial |
$241.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$235.70
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$18,038.92
|
|
|
Service Code
|
MS-DRG 748
|
| Min. Negotiated Rate |
$12,896.61 |
| Max. Negotiated Rate |
$18,038.92 |
| Rate for Payer: Aetna Medicare |
$13,575.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16,969.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16,969.22
|
| Rate for Payer: BCBS MAPPO |
$13,575.38
|
| Rate for Payer: BCN Medicare Advantage |
$13,575.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,575.38
|
| Rate for Payer: Humana Choice PPO Medicare |
$13,575.38
|
| Rate for Payer: Mclaren Medicare |
$13,575.38
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,254.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,611.69
|
| Rate for Payer: PACE Medicare |
$12,896.61
|
| Rate for Payer: PACE SWMI |
$13,575.38
|
| Rate for Payer: PHP Commercial |
$14,932.92
|
| Rate for Payer: PHP Medicare Advantage |
$13,575.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,038.92
|
| Rate for Payer: Priority Health Medicare |
$13,575.38
|
| Rate for Payer: Priority Health Narrow Network |
$14,431.14
|
| Rate for Payer: Railroad Medicare Medicare |
$13,575.38
|
| Rate for Payer: UHC Medicare Advantage |
$13,982.64
|
| Rate for Payer: VA VA |
$13,575.38
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH
|
Facility
|
IP
|
$153.22
|
|
|
Service Code
|
NDC 0378-9119-98
|
| Hospital Charge Code |
41382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.25 |
| Max. Negotiated Rate |
$153.22 |
| Rate for Payer: Aetna Commercial |
$137.90
|
| Rate for Payer: ASR ASR |
$148.62
|
| Rate for Payer: BCBS Trust/PPO |
$118.79
|
| Rate for Payer: BCN Commercial |
$118.79
|
| Rate for Payer: Cash Price |
$122.58
|
| Rate for Payer: Cofinity Commercial |
$144.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.58
|
| Rate for Payer: Healthscope Commercial |
$153.22
|
| Rate for Payer: Healthscope Whirlpool |
$148.62
|
| Rate for Payer: Mclaren Commercial |
$137.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.83
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH
|
Facility
|
IP
|
$153.22
|
|
|
Service Code
|
NDC 0378-9119-16
|
| Hospital Charge Code |
41382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.25 |
| Max. Negotiated Rate |
$153.22 |
| Rate for Payer: Aetna Commercial |
$137.90
|
| Rate for Payer: ASR ASR |
$148.62
|
| Rate for Payer: BCBS Trust/PPO |
$118.79
|
| Rate for Payer: BCN Commercial |
$118.79
|
| Rate for Payer: Cash Price |
$122.58
|
| Rate for Payer: Cofinity Commercial |
$144.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.58
|
| Rate for Payer: Healthscope Commercial |
$153.22
|
| Rate for Payer: Healthscope Whirlpool |
$148.62
|
| Rate for Payer: Mclaren Commercial |
$137.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.83
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH
|
Facility
|
IP
|
$46.68
|
|
|
Service Code
|
NDC 60505-7006-2
|
| Hospital Charge Code |
27905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.68 |
| Max. Negotiated Rate |
$46.68 |
| Rate for Payer: Aetna Commercial |
$42.01
|
| Rate for Payer: ASR ASR |
$45.28
|
| Rate for Payer: BCBS Trust/PPO |
$36.19
|
| Rate for Payer: BCN Commercial |
$36.19
|
| Rate for Payer: Cash Price |
$37.35
|
| Rate for Payer: Cofinity Commercial |
$43.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.34
|
| Rate for Payer: Healthscope Commercial |
$46.68
|
| Rate for Payer: Healthscope Whirlpool |
$45.28
|
| Rate for Payer: Mclaren Commercial |
$42.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.08
|
|
