|
FRAXEL PARTIAL TREATMENT - UPPER LIP
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 00158
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: BCBS Complete |
$100.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.00
|
|
|
FRAXEL RESTORE
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 00168
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$100.00 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: BCBS Complete |
$100.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.00
|
|
|
FRAXEL SMALL SCAR
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 00159
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$50.00 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: BCBS Complete |
$50.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.50
|
|
|
FRAXEL STRETCH MARKS - ENTIRE ABDOMEN
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 00165
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$320.00 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: BCBS Complete |
$320.00
|
| Rate for Payer: Cash Price |
$640.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$560.00
|
|
|
FRAXEL STRETCH MARKS - PERI-UMBILICAL
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 00164
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: BCBS Complete |
$240.00
|
| Rate for Payer: Cash Price |
$480.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$420.00
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$54,047.41
|
|
|
Service Code
|
MS-DRG 793
|
| Min. Negotiated Rate |
$35,452.62 |
| Max. Negotiated Rate |
$54,047.41 |
| Rate for Payer: Aetna Medicare |
$37,318.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46,648.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46,648.19
|
| Rate for Payer: BCBS MAPPO |
$37,318.55
|
| Rate for Payer: BCN Medicare Advantage |
$37,318.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37,318.55
|
| Rate for Payer: Humana Choice PPO Medicare |
$37,318.55
|
| Rate for Payer: Mclaren Medicare |
$37,318.55
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$39,184.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42,916.33
|
| Rate for Payer: PACE Medicare |
$35,452.62
|
| Rate for Payer: PACE SWMI |
$37,318.55
|
| Rate for Payer: PHP Commercial |
$41,050.40
|
| Rate for Payer: PHP Medicare Advantage |
$37,318.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$54,047.41
|
| Rate for Payer: Priority Health Medicare |
$37,318.55
|
| Rate for Payer: Priority Health Narrow Network |
$43,237.93
|
| Rate for Payer: Railroad Medicare Medicare |
$37,318.55
|
| Rate for Payer: UHC Medicare Advantage |
$38,438.11
|
| Rate for Payer: VA VA |
$37,318.55
|
|
|
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY
|
Facility
|
IP
|
$26,867.70
|
|
|
Service Code
|
MS-DRG 934
|
| Min. Negotiated Rate |
$18,427.04 |
| Max. Negotiated Rate |
$26,867.70 |
| Rate for Payer: Aetna Medicare |
$19,396.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,246.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,246.10
|
| Rate for Payer: BCBS MAPPO |
$19,396.88
|
| Rate for Payer: BCN Medicare Advantage |
$19,396.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,396.88
|
| Rate for Payer: Humana Choice PPO Medicare |
$19,396.88
|
| Rate for Payer: Mclaren Medicare |
$19,396.88
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$20,366.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,306.41
|
| Rate for Payer: PACE Medicare |
$18,427.04
|
| Rate for Payer: PACE SWMI |
$19,396.88
|
| Rate for Payer: PHP Commercial |
$21,336.57
|
| Rate for Payer: PHP Medicare Advantage |
$19,396.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26,867.70
|
| Rate for Payer: Priority Health Medicare |
$19,396.88
|
| Rate for Payer: Priority Health Narrow Network |
$21,494.16
|
| Rate for Payer: Railroad Medicare Medicare |
$19,396.88
|
| Rate for Payer: UHC Medicare Advantage |
$19,978.79
|
| Rate for Payer: VA VA |
$19,396.88
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC
|
Facility
|
IP
|
$88,848.95
|
|
|
Service Code
|
MS-DRG 928
|
| Min. Negotiated Rate |
$57,252.57 |
| Max. Negotiated Rate |
$88,848.95 |
| Rate for Payer: Aetna Medicare |
$60,265.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$75,332.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$75,332.32
|
| Rate for Payer: BCBS MAPPO |
$60,265.86
|
| Rate for Payer: BCN Medicare Advantage |
$60,265.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$60,265.86
|
| Rate for Payer: Humana Choice PPO Medicare |
$60,265.86
|
| Rate for Payer: Mclaren Medicare |
$60,265.86
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$63,279.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$69,305.74
|
| Rate for Payer: PACE Medicare |
$57,252.57
|
| Rate for Payer: PACE SWMI |
$60,265.86
|
| Rate for Payer: PHP Commercial |
$66,292.45
|
| Rate for Payer: PHP Medicare Advantage |
$60,265.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$88,848.95
|
| Rate for Payer: Priority Health Medicare |
$60,265.86
|
| Rate for Payer: Priority Health Narrow Network |
$71,079.16
|
| Rate for Payer: Railroad Medicare Medicare |
$60,265.86
|
| Rate for Payer: UHC Medicare Advantage |
$62,073.84
|
| Rate for Payer: VA VA |
$60,265.86
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC
|
Facility
|
IP
|
$41,287.02
|
|
|
Service Code
|
MS-DRG 929
|
| Min. Negotiated Rate |
$27,459.41 |
| Max. Negotiated Rate |
$41,287.02 |
| Rate for Payer: Aetna Medicare |
$28,904.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$36,130.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$36,130.80
|
| Rate for Payer: BCBS MAPPO |
$28,904.64
|
| Rate for Payer: BCN Medicare Advantage |
$28,904.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$28,904.64
|
| Rate for Payer: Humana Choice PPO Medicare |
$28,904.64
|
| Rate for Payer: Mclaren Medicare |
$28,904.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$30,349.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33,240.34
|
| Rate for Payer: PACE Medicare |
$27,459.41
|
| Rate for Payer: PACE SWMI |
$28,904.64
|
| Rate for Payer: PHP Commercial |
$31,795.10
|
| Rate for Payer: PHP Medicare Advantage |
$28,904.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$41,287.02
|
| Rate for Payer: Priority Health Medicare |
$28,904.64
|
| Rate for Payer: Priority Health Narrow Network |
$33,029.62
|
| Rate for Payer: Railroad Medicare Medicare |
$28,904.64
|
| Rate for Payer: UHC Medicare Advantage |
$29,771.78
|
| Rate for Payer: VA VA |
$28,904.64
|
|
|
FUROSEMIDE 10 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$10.93
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
163713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$10.93 |
| Rate for Payer: Aetna Commercial |
$9.84
|
| Rate for Payer: Aetna Commercial |
$14.22
|
| Rate for Payer: Aetna Commercial |
$12.40
|
| Rate for Payer: Aetna Commercial |
$25.37
|
| Rate for Payer: Aetna Commercial |
$15.03
|
| Rate for Payer: ASR ASR |
$15.33
|
| Rate for Payer: ASR ASR |
$10.60
|
| Rate for Payer: ASR ASR |
$13.37
|
| Rate for Payer: ASR ASR |
$16.20
|
| Rate for Payer: ASR ASR |
$27.34
|
| Rate for Payer: BCBS Trust/PPO |
$10.68
|
| Rate for Payer: BCBS Trust/PPO |
$12.95
|
| Rate for Payer: BCBS Trust/PPO |
$8.47
|
| Rate for Payer: BCBS Trust/PPO |
$12.25
|
| Rate for Payer: BCBS Trust/PPO |
$21.86
|
| Rate for Payer: BCN Commercial |
$12.95
|
| Rate for Payer: BCN Commercial |
$10.68
|
| Rate for Payer: BCN Commercial |
$21.86
|
| Rate for Payer: BCN Commercial |
$8.47
|
| Rate for Payer: BCN Commercial |
$12.25
|
| Rate for Payer: Cash Price |
$12.64
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cash Price |
$13.36
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$14.85
|
| Rate for Payer: Cofinity Commercial |
$10.27
|
| Rate for Payer: Cofinity Commercial |
$26.50
|
| Rate for Payer: Cofinity Commercial |
$15.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.36
|
| Rate for Payer: Healthscope Commercial |
$16.70
|
| Rate for Payer: Healthscope Commercial |
$13.78
|
| Rate for Payer: Healthscope Commercial |
$15.80
|
| Rate for Payer: Healthscope Commercial |
$28.19
|
| Rate for Payer: Healthscope Commercial |
$10.93
|
| Rate for Payer: Healthscope Whirlpool |
$13.37
|
| Rate for Payer: Healthscope Whirlpool |
$15.33
|
| Rate for Payer: Healthscope Whirlpool |
$16.20
|
| Rate for Payer: Healthscope Whirlpool |
$27.34
|
| Rate for Payer: Healthscope Whirlpool |
$10.60
|
| Rate for Payer: Mclaren Commercial |
$9.84
|
| Rate for Payer: Mclaren Commercial |
$12.40
|
| Rate for Payer: Mclaren Commercial |
$25.37
|
| Rate for Payer: Mclaren Commercial |
$15.03
|
| Rate for Payer: Mclaren Commercial |
$14.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.90
|
|
|
FUROSEMIDE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$15.14
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
3291
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Aetna Commercial |
$13.63
|
| Rate for Payer: Aetna Commercial |
$9.60
|
| Rate for Payer: Aetna Commercial |
$25.37
|
| Rate for Payer: Aetna Commercial |
$12.47
|
| Rate for Payer: Aetna Commercial |
$12.40
|
| Rate for Payer: Aetna Commercial |
$9.84
|
| Rate for Payer: Aetna Commercial |
$14.22
|
| Rate for Payer: Aetna Commercial |
$12.64
|
| Rate for Payer: Aetna Commercial |
$17.96
|
| Rate for Payer: Aetna Commercial |
$11.16
|
| Rate for Payer: Aetna Commercial |
$15.03
|
| Rate for Payer: ASR ASR |
$10.60
|
| Rate for Payer: ASR ASR |
$15.33
|
| Rate for Payer: ASR ASR |
$13.62
|
| Rate for Payer: ASR ASR |
$10.35
|
| Rate for Payer: ASR ASR |
$13.44
|
| Rate for Payer: ASR ASR |
$12.03
|
| Rate for Payer: ASR ASR |
$19.35
|
| Rate for Payer: ASR ASR |
$13.37
|
| Rate for Payer: ASR ASR |
$14.69
|
| Rate for Payer: ASR ASR |
$27.34
|
| Rate for Payer: ASR ASR |
$16.20
|
| Rate for Payer: BCBS Trust/PPO |
$12.95
|
| Rate for Payer: BCBS Trust/PPO |
$8.47
|
| Rate for Payer: BCBS Trust/PPO |
$9.61
|
| Rate for Payer: BCBS Trust/PPO |
$10.89
|
| Rate for Payer: BCBS Trust/PPO |
$12.25
|
| Rate for Payer: BCBS Trust/PPO |
$15.47
|
| Rate for Payer: BCBS Trust/PPO |
$11.74
|
| Rate for Payer: BCBS Trust/PPO |
$8.27
|
| Rate for Payer: BCBS Trust/PPO |
$10.68
|
| Rate for Payer: BCBS Trust/PPO |
$10.75
|
| Rate for Payer: BCBS Trust/PPO |
$21.86
|
| Rate for Payer: BCN Commercial |
$10.68
|
| Rate for Payer: BCN Commercial |
$8.27
|
| Rate for Payer: BCN Commercial |
$10.75
|
| Rate for Payer: BCN Commercial |
$21.86
|
| Rate for Payer: BCN Commercial |
$15.47
|
| Rate for Payer: BCN Commercial |
$8.47
|
| Rate for Payer: BCN Commercial |
$12.95
|
| Rate for Payer: BCN Commercial |
$9.61
|
| Rate for Payer: BCN Commercial |
$12.25
|
| Rate for Payer: BCN Commercial |
$11.74
|
| Rate for Payer: BCN Commercial |
$10.89
|
| Rate for Payer: Cash Price |
$11.09
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cash Price |
$12.64
|
| Rate for Payer: Cash Price |
$9.92
|
| Rate for Payer: Cash Price |
$13.36
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Cash Price |
$8.75
|
| Rate for Payer: Cash Price |
$15.96
|
| Rate for Payer: Cash Price |
$12.11
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cofinity Commercial |
$13.03
|
| Rate for Payer: Cofinity Commercial |
$10.03
|
| Rate for Payer: Cofinity Commercial |
$10.27
|
| Rate for Payer: Cofinity Commercial |
$11.66
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Commercial |
$13.20
|
| Rate for Payer: Cofinity Commercial |
$14.23
|
| Rate for Payer: Cofinity Commercial |
$14.85
|
| Rate for Payer: Cofinity Commercial |
$15.70
|
| Rate for Payer: Cofinity Commercial |
$18.75
|
| Rate for Payer: Cofinity Commercial |
$26.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.55
|
| Rate for Payer: Healthscope Commercial |
$10.67
|
| Rate for Payer: Healthscope Commercial |
$10.93
|
| Rate for Payer: Healthscope Commercial |
$16.70
|
| Rate for Payer: Healthscope Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$12.40
|
| Rate for Payer: Healthscope Commercial |
$15.80
|
| Rate for Payer: Healthscope Commercial |
$19.95
|
| Rate for Payer: Healthscope Commercial |
$28.19
|
| Rate for Payer: Healthscope Commercial |
$13.78
|
| Rate for Payer: Healthscope Commercial |
$14.04
|
| Rate for Payer: Healthscope Commercial |
$15.14
|
| Rate for Payer: Healthscope Whirlpool |
$10.35
|
| Rate for Payer: Healthscope Whirlpool |
$13.62
|
| Rate for Payer: Healthscope Whirlpool |
$27.34
|
| Rate for Payer: Healthscope Whirlpool |
$13.44
|
| Rate for Payer: Healthscope Whirlpool |
$13.37
|
| Rate for Payer: Healthscope Whirlpool |
$15.33
|
| Rate for Payer: Healthscope Whirlpool |
$19.35
|
| Rate for Payer: Healthscope Whirlpool |
$14.69
|
| Rate for Payer: Healthscope Whirlpool |
$10.60
|
| Rate for Payer: Healthscope Whirlpool |
$12.03
|
| Rate for Payer: Healthscope Whirlpool |
$16.20
|
| Rate for Payer: Mclaren Commercial |
$9.84
|
| Rate for Payer: Mclaren Commercial |
$12.64
|
| Rate for Payer: Mclaren Commercial |
$12.40
|
| Rate for Payer: Mclaren Commercial |
$13.63
|
| Rate for Payer: Mclaren Commercial |
$11.16
|
| Rate for Payer: Mclaren Commercial |
$14.22
|
| Rate for Payer: Mclaren Commercial |
$15.03
|
| Rate for Payer: Mclaren Commercial |
$12.47
|
| Rate for Payer: Mclaren Commercial |
$17.96
|
| Rate for Payer: Mclaren Commercial |
$9.60
|
| Rate for Payer: Mclaren Commercial |
$25.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.62
|
|
|
FUROSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$1.41
|
|
|
Service Code
|
NDC 51079-072-01
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: ASR ASR |
$1.37
|
| Rate for Payer: BCBS Trust/PPO |
$1.09
|
| Rate for Payer: BCN Commercial |
$1.09
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$1.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.13
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Healthscope Whirlpool |
$1.37
|
| Rate for Payer: Mclaren Commercial |
$1.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.24
|
|
|
FUROSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$126.90
|
|
|
Service Code
|
NDC 0904-7177-61
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.83 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna Commercial |
$114.21
|
| Rate for Payer: ASR ASR |
$123.09
|
| Rate for Payer: BCBS Trust/PPO |
$98.39
|
| Rate for Payer: BCN Commercial |
$98.39
|
| Rate for Payer: Cash Price |
$101.52
|
| Rate for Payer: Cofinity Commercial |
$119.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.52
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Healthscope Whirlpool |
$123.09
|
| Rate for Payer: Mclaren Commercial |
$114.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$111.67
|
|
|
FUROSEMIDE 40 MG TABLET
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 51079-073-01
|
| Hospital Charge Code |
3295
|
|
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
|
|
|
FUROSEMIDE 80 MG TABLET
|
Facility
|
IP
|
$89.30
|
|
|
Service Code
|
NDC 0781-1446-01
|
| Hospital Charge Code |
3296
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.51 |
| Max. Negotiated Rate |
$89.30 |
| Rate for Payer: Aetna Commercial |
$80.37
|
| Rate for Payer: ASR ASR |
$86.62
|
| Rate for Payer: BCBS Trust/PPO |
$69.23
|
| Rate for Payer: BCN Commercial |
$69.23
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$83.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$89.30
|
| Rate for Payer: Healthscope Whirlpool |
$86.62
|
| Rate for Payer: Mclaren Commercial |
$80.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$78.58
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 0904-6665-61
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.73 |
| Max. Negotiated Rate |
$173.90 |
| Rate for Payer: Aetna Commercial |
$156.51
|
| Rate for Payer: ASR ASR |
$168.68
|
| Rate for Payer: BCBS Trust/PPO |
$134.82
|
| Rate for Payer: BCN Commercial |
$134.82
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$163.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$173.90
|
| Rate for Payer: Healthscope Whirlpool |
$168.68
|
| Rate for Payer: Mclaren Commercial |
$156.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$153.03
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$190.35
|
|
|
Service Code
|
NDC 63739-591-10
|
| Hospital Charge Code |
18309
|
|
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
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$218.50
|
|
|
Service Code
|
NDC 60505-0112-0
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.95 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna Commercial |
$196.65
|
| Rate for Payer: ASR ASR |
$211.94
|
| Rate for Payer: BCBS Trust/PPO |
$169.40
|
| Rate for Payer: BCN Commercial |
$169.40
|
| Rate for Payer: Cash Price |
$174.80
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.80
|
| Rate for Payer: Healthscope Commercial |
$218.50
|
| Rate for Payer: Healthscope Whirlpool |
$211.94
|
| Rate for Payer: Mclaren Commercial |
$196.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$192.28
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$79.90
|
|
|
Service Code
|
NDC 67877-222-01
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.93 |
| Max. Negotiated Rate |
$79.90 |
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: ASR ASR |
$77.50
|
| Rate for Payer: BCBS Trust/PPO |
$61.95
|
| Rate for Payer: BCN Commercial |
$61.95
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$75.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$79.90
|
| Rate for Payer: Healthscope Whirlpool |
$77.50
|
| Rate for Payer: Mclaren Commercial |
$71.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.31
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 68084-762-11
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.12
|
| Rate for Payer: ASR ASR |
$2.28
|
| Rate for Payer: BCBS Trust/PPO |
$1.82
|
| Rate for Payer: BCN Commercial |
$1.82
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.88
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Healthscope Whirlpool |
$2.28
|
| Rate for Payer: Mclaren Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.07
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
NDC 67877-223-01
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.74 |
| Max. Negotiated Rate |
$101.05 |
| Rate for Payer: Aetna Commercial |
$90.94
|
| Rate for Payer: ASR ASR |
$98.02
|
| Rate for Payer: BCBS Trust/PPO |
$78.34
|
| Rate for Payer: BCN Commercial |
$78.34
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$101.05
|
| Rate for Payer: Healthscope Whirlpool |
$98.02
|
| Rate for Payer: Mclaren Commercial |
$90.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$88.92
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$249.10
|
|
|
Service Code
|
NDC 0904-6666-61
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.37 |
| Max. Negotiated Rate |
$249.10 |
| Rate for Payer: Aetna Commercial |
$224.19
|
| Rate for Payer: ASR ASR |
$241.63
|
| Rate for Payer: BCBS Trust/PPO |
$193.13
|
| Rate for Payer: BCN Commercial |
$193.13
|
| Rate for Payer: Cash Price |
$199.28
|
| Rate for Payer: Cofinity Commercial |
$234.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.28
|
| Rate for Payer: Healthscope Commercial |
$249.10
|
| Rate for Payer: Healthscope Whirlpool |
$241.63
|
| Rate for Payer: Mclaren Commercial |
$224.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$211.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$219.21
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
NDC 68084-762-01
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.50 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$211.50
|
| Rate for Payer: ASR ASR |
$227.95
|
| Rate for Payer: BCBS Trust/PPO |
$182.20
|
| Rate for Payer: BCN Commercial |
$182.20
|
| Rate for Payer: Cash Price |
$188.00
|
| Rate for Payer: Cofinity Commercial |
$220.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.00
|
| Rate for Payer: Healthscope Commercial |
$235.00
|
| Rate for Payer: Healthscope Whirlpool |
$227.95
|
| Rate for Payer: Mclaren Commercial |
$211.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$199.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$206.80
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$239.70
|
|
|
Service Code
|
NDC 63739-984-10
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.79 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: ASR ASR |
$232.51
|
| Rate for Payer: BCBS Trust/PPO |
$185.84
|
| Rate for Payer: BCN Commercial |
$185.84
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$225.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$239.70
|
| Rate for Payer: Healthscope Whirlpool |
$232.51
|
| Rate for Payer: Mclaren Commercial |
$215.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$203.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$210.94
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 0904-6667-61
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.53 |
| Max. Negotiated Rate |
$267.90 |
| Rate for Payer: Aetna Commercial |
$241.11
|
| Rate for Payer: ASR ASR |
$259.86
|
| Rate for Payer: BCBS Trust/PPO |
$207.70
|
| Rate for Payer: BCN Commercial |
$207.70
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$251.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$267.90
|
| Rate for Payer: Healthscope Whirlpool |
$259.86
|
| Rate for Payer: Mclaren Commercial |
$241.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$235.75
|
|
