|
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$146.94
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
29132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.86 |
| Max. Negotiated Rate |
$146.94 |
| Rate for Payer: Aetna Commercial |
$132.25
|
| Rate for Payer: ASR ASR |
$142.53
|
| Rate for Payer: BCBS Trust/PPO |
$113.92
|
| Rate for Payer: BCN Commercial |
$113.92
|
| Rate for Payer: Cash Price |
$117.55
|
| Rate for Payer: Cofinity Commercial |
$138.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.55
|
| Rate for Payer: Healthscope Commercial |
$146.94
|
| Rate for Payer: Healthscope Whirlpool |
$142.53
|
| Rate for Payer: Mclaren Commercial |
$132.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$124.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$129.31
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC
|
Facility
|
IP
|
$24,032.63
|
|
|
Service Code
|
MS-DRG 062
|
| Min. Negotiated Rate |
$16,651.12 |
| Max. Negotiated Rate |
$24,032.63 |
| Rate for Payer: Aetna Medicare |
$17,527.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,909.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,909.38
|
| Rate for Payer: BCBS MAPPO |
$17,527.50
|
| Rate for Payer: BCN Medicare Advantage |
$17,527.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,527.50
|
| Rate for Payer: Humana Choice PPO Medicare |
$17,527.50
|
| Rate for Payer: Mclaren Medicare |
$17,527.50
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$18,403.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20,156.62
|
| Rate for Payer: PACE Medicare |
$16,651.12
|
| Rate for Payer: PACE SWMI |
$17,527.50
|
| Rate for Payer: PHP Commercial |
$19,280.25
|
| Rate for Payer: PHP Medicare Advantage |
$17,527.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24,032.63
|
| Rate for Payer: Priority Health Medicare |
$17,527.50
|
| Rate for Payer: Priority Health Narrow Network |
$19,226.10
|
| Rate for Payer: Railroad Medicare Medicare |
$17,527.50
|
| Rate for Payer: UHC Medicare Advantage |
$18,053.32
|
| Rate for Payer: VA VA |
$17,527.50
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC
|
Facility
|
IP
|
$35,987.95
|
|
|
Service Code
|
MS-DRG 061
|
| Min. Negotiated Rate |
$24,140.02 |
| Max. Negotiated Rate |
$35,987.95 |
| Rate for Payer: Aetna Medicare |
$25,410.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31,763.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31,763.19
|
| Rate for Payer: BCBS MAPPO |
$25,410.55
|
| Rate for Payer: BCN Medicare Advantage |
$25,410.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25,410.55
|
| Rate for Payer: Humana Choice PPO Medicare |
$25,410.55
|
| Rate for Payer: Mclaren Medicare |
$25,410.55
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$26,681.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29,222.13
|
| Rate for Payer: PACE Medicare |
$24,140.02
|
| Rate for Payer: PACE SWMI |
$25,410.55
|
| Rate for Payer: PHP Commercial |
$27,951.60
|
| Rate for Payer: PHP Medicare Advantage |
$25,410.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$35,987.95
|
| Rate for Payer: Priority Health Medicare |
$25,410.55
|
| Rate for Payer: Priority Health Narrow Network |
$28,790.36
|
| Rate for Payer: Railroad Medicare Medicare |
$25,410.55
|
| Rate for Payer: UHC Medicare Advantage |
$26,172.87
|
| Rate for Payer: VA VA |
$25,410.55
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC
|
Facility
|
IP
|
$19,090.51
|
|
|
Service Code
|
MS-DRG 063
|
| Min. Negotiated Rate |
$13,555.34 |
| Max. Negotiated Rate |
$19,090.51 |
| Rate for Payer: Aetna Medicare |
$14,268.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,835.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,835.98
|
| Rate for Payer: BCBS MAPPO |
$14,268.78
|
| Rate for Payer: BCN Medicare Advantage |
$14,268.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,268.78
|
| Rate for Payer: Humana Choice PPO Medicare |
$14,268.78
|
| Rate for Payer: Mclaren Medicare |
$14,268.78
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,982.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,409.10
|
| Rate for Payer: PACE Medicare |
$13,555.34
|
| Rate for Payer: PACE SWMI |
$14,268.78
|
| Rate for Payer: PHP Commercial |
$15,695.66
|
| Rate for Payer: PHP Medicare Advantage |
$14,268.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19,090.51
|
| Rate for Payer: Priority Health Medicare |
$14,268.78
|
| Rate for Payer: Priority Health Narrow Network |
$15,272.41
|
| Rate for Payer: Railroad Medicare Medicare |
$14,268.78
|
| Rate for Payer: UHC Medicare Advantage |
$14,696.84
|
| Rate for Payer: VA VA |
$14,268.78
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
NDC 68084-083-11
|
| Hospital Charge Code |
4065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Aetna Commercial |
$2.97
|
| Rate for Payer: ASR ASR |
$3.20
|
| Rate for Payer: BCBS Trust/PPO |
$2.56
|
| Rate for Payer: BCN Commercial |
$2.56
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Cofinity Commercial |
$3.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.64
|
| Rate for Payer: Healthscope Commercial |
$3.30
|
| Rate for Payer: Healthscope Whirlpool |
$3.20
|
| Rate for Payer: Mclaren Commercial |
$2.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.90
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET
|
Facility
|
IP
|
$330.24
|
|
|
Service Code
|
NDC 68084-083-01
|
| Hospital Charge Code |
4065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.17 |
| Max. Negotiated Rate |
$330.24 |
| Rate for Payer: Aetna Commercial |
$297.22
|
| Rate for Payer: ASR ASR |
$320.33
|
| Rate for Payer: BCBS Trust/PPO |
$256.04
|
| Rate for Payer: BCN Commercial |
$256.04
|
| Rate for Payer: Cash Price |
$264.19
|
| Rate for Payer: Cofinity Commercial |
$310.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.19
|
| Rate for Payer: Healthscope Commercial |
$330.24
|
| Rate for Payer: Healthscope Whirlpool |
$320.33
|
| Rate for Payer: Mclaren Commercial |
$297.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$280.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$290.61
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET
|
Facility
|
IP
|
$468.35
|
|
|
Service Code
|
NDC 0904-6620-61
|
| Hospital Charge Code |
4065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$327.84 |
| Max. Negotiated Rate |
$468.35 |
| Rate for Payer: Aetna Commercial |
$421.52
|
| Rate for Payer: ASR ASR |
$454.30
|
| Rate for Payer: BCBS Trust/PPO |
$363.11
|
| Rate for Payer: BCN Commercial |
$363.11
|
| Rate for Payer: Cash Price |
$374.68
|
| Rate for Payer: Cofinity Commercial |
$440.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$374.68
|
| Rate for Payer: Healthscope Commercial |
$468.35
|
| Rate for Payer: Healthscope Whirlpool |
$454.30
|
| Rate for Payer: Mclaren Commercial |
$421.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$398.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$327.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$412.15
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET
|
Facility
|
IP
|
$284.64
|
|
|
Service Code
|
NDC 0781-1695-13
|
| Hospital Charge Code |
4065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.25 |
| Max. Negotiated Rate |
$284.64 |
| Rate for Payer: Aetna Commercial |
$256.18
|
| Rate for Payer: ASR ASR |
$276.10
|
| Rate for Payer: BCBS Trust/PPO |
$220.68
|
| Rate for Payer: BCN Commercial |
$220.68
|
| Rate for Payer: Cash Price |
$227.71
|
| Rate for Payer: Cofinity Commercial |
$267.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.71
|
| Rate for Payer: Healthscope Commercial |
$284.64
|
| Rate for Payer: Healthscope Whirlpool |
$276.10
|
| Rate for Payer: Mclaren Commercial |
$256.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$250.48
|
|
|
ISOSORBIDE MONONITRATE 20 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 0228-2620-11
|
| Hospital Charge Code |
10357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.36 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.76
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: BCBS Trust/PPO |
$249.61
|
| Rate for Payer: BCN Commercial |
$249.61
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$302.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$321.95
|
| Rate for Payer: Healthscope Whirlpool |
$312.29
|
| Rate for Payer: Mclaren Commercial |
$289.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.32
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$464.55
|
|
|
Service Code
|
NDC 68084-591-01
|
| Hospital Charge Code |
24521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$325.18 |
| Max. Negotiated Rate |
$464.55 |
| Rate for Payer: Aetna Commercial |
$418.10
|
| Rate for Payer: ASR ASR |
$450.61
|
| Rate for Payer: BCBS Trust/PPO |
$360.17
|
| Rate for Payer: BCN Commercial |
$360.17
|
| Rate for Payer: Cash Price |
$371.64
|
| Rate for Payer: Cofinity Commercial |
$436.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$371.64
|
| Rate for Payer: Healthscope Commercial |
$464.55
|
| Rate for Payer: Healthscope Whirlpool |
$450.61
|
| Rate for Payer: Mclaren Commercial |
$418.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$394.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$325.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$408.80
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$243.20
|
|
|
Service Code
|
NDC 0904-6449-61
|
| Hospital Charge Code |
24521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.24 |
| Max. Negotiated Rate |
$243.20 |
| Rate for Payer: Aetna Commercial |
$218.88
|
| Rate for Payer: ASR ASR |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$188.55
|
| Rate for Payer: BCN Commercial |
$188.55
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Commercial |
$228.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$243.20
|
| Rate for Payer: Healthscope Whirlpool |
$235.90
|
| Rate for Payer: Mclaren Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$214.02
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4.65
|
|
|
Service Code
|
NDC 68084-591-11
|
| Hospital Charge Code |
24521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$4.65 |
| Rate for Payer: Aetna Commercial |
$4.18
|
| Rate for Payer: ASR ASR |
$4.51
|
| Rate for Payer: BCBS Trust/PPO |
$3.61
|
| Rate for Payer: BCN Commercial |
$3.61
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Cofinity Commercial |
$4.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.72
|
| Rate for Payer: Healthscope Commercial |
$4.65
|
| Rate for Payer: Healthscope Whirlpool |
$4.51
|
| Rate for Payer: Mclaren Commercial |
$4.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.09
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
NDC 50268-452-11
|
| Hospital Charge Code |
24268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Aetna Commercial |
$3.04
|
| Rate for Payer: ASR ASR |
$3.28
|
| Rate for Payer: BCBS Trust/PPO |
$2.62
|
| Rate for Payer: BCN Commercial |
$2.62
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cofinity Commercial |
$3.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.70
|
| Rate for Payer: Healthscope Commercial |
$3.38
|
| Rate for Payer: Healthscope Whirlpool |
$3.28
|
| Rate for Payer: Mclaren Commercial |
$3.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.97
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$289.75
|
|
|
Service Code
|
NDC 0904-6450-61
|
| Hospital Charge Code |
24268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.82 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna Commercial |
$260.78
|
| Rate for Payer: ASR ASR |
$281.06
|
| Rate for Payer: BCBS Trust/PPO |
$224.64
|
| Rate for Payer: BCN Commercial |
$224.64
|
| Rate for Payer: Cash Price |
$231.80
|
| Rate for Payer: Cofinity Commercial |
$272.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.80
|
| Rate for Payer: Healthscope Commercial |
$289.75
|
| Rate for Payer: Healthscope Whirlpool |
$281.06
|
| Rate for Payer: Mclaren Commercial |
$260.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$246.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$254.98
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$168.72
|
|
|
Service Code
|
NDC 50268-452-15
|
| Hospital Charge Code |
24268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.10 |
| Max. Negotiated Rate |
$168.72 |
| Rate for Payer: Aetna Commercial |
$151.85
|
| Rate for Payer: ASR ASR |
$163.66
|
| Rate for Payer: BCBS Trust/PPO |
$130.81
|
| Rate for Payer: BCN Commercial |
$130.81
|
| Rate for Payer: Cash Price |
$134.98
|
| Rate for Payer: Cofinity Commercial |
$158.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.98
|
| Rate for Payer: Healthscope Commercial |
$168.72
|
| Rate for Payer: Healthscope Whirlpool |
$163.66
|
| Rate for Payer: Mclaren Commercial |
$151.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$143.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$148.47
|
|
|
ISOSOURCE 1.5 BOLUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018150
|
| Hospital Charge Code |
150768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
ISOSOURCE 1.5 CONTINUOUS FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 4390018181
|
| Hospital Charge Code |
168943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna Commercial |
$8.64
|
| Rate for Payer: ASR ASR |
$9.31
|
| Rate for Payer: BCBS Trust/PPO |
$7.44
|
| Rate for Payer: BCN Commercial |
$7.44
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$9.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$9.60
|
| Rate for Payer: Healthscope Whirlpool |
$9.31
|
| Rate for Payer: Mclaren Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.45
|
|
|
ISOSOURCE 1.5 CONTINUOUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018150
|
| Hospital Charge Code |
168943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
ISOSOURCE 1.5 CYCLIC FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018150
|
| Hospital Charge Code |
200081
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
ISOSOURCE 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018150
|
| Hospital Charge Code |
200080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
ISOSOURCE HN BOLUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018457
|
| Hospital Charge Code |
150769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
ISOSOURCE HN CONTINUOUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018457
|
| Hospital Charge Code |
168942
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
ISOSOURCE HN CYCLIC FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018457
|
| Hospital Charge Code |
200075
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
ISOSOURCE HN INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018457
|
| Hospital Charge Code |
200074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.28
|
| Rate for Payer: ASR ASR |
$4.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.75
|
| Rate for Payer: Healthscope Whirlpool |
$4.61
|
| Rate for Payer: Mclaren Commercial |
$4.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.18
|
|
|
ISOSOURCE HN ORAL LIQUID
|
Facility
|
IP
|
$44.56
|
|
|
Service Code
|
NDC 7007456016
|
| Hospital Charge Code |
157366
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.19 |
| Max. Negotiated Rate |
$44.56 |
| Rate for Payer: Aetna Commercial |
$40.10
|
| Rate for Payer: ASR ASR |
$43.22
|
| Rate for Payer: BCBS Trust/PPO |
$34.55
|
| Rate for Payer: BCN Commercial |
$34.55
|
| Rate for Payer: Cash Price |
$35.64
|
| Rate for Payer: Cofinity Commercial |
$41.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.65
|
| Rate for Payer: Healthscope Commercial |
$44.56
|
| Rate for Payer: Healthscope Whirlpool |
$43.22
|
| Rate for Payer: Mclaren Commercial |
$40.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.21
|
|
