|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$128.40
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.88 |
| Max. Negotiated Rate |
$128.40 |
| Rate for Payer: Aetna Commercial |
$115.56
|
| Rate for Payer: Aetna Commercial |
$28.89
|
| Rate for Payer: Aetna Commercial |
$86.67
|
| Rate for Payer: ASR ASR |
$31.14
|
| Rate for Payer: ASR ASR |
$124.55
|
| Rate for Payer: ASR ASR |
$93.41
|
| Rate for Payer: BCBS Trust/PPO |
$74.66
|
| Rate for Payer: BCBS Trust/PPO |
$99.55
|
| Rate for Payer: BCBS Trust/PPO |
$24.89
|
| Rate for Payer: BCN Commercial |
$24.89
|
| Rate for Payer: BCN Commercial |
$99.55
|
| Rate for Payer: BCN Commercial |
$74.66
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cofinity Commercial |
$90.52
|
| Rate for Payer: Cofinity Commercial |
$120.70
|
| Rate for Payer: Cofinity Commercial |
$30.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.72
|
| Rate for Payer: Healthscope Commercial |
$96.30
|
| Rate for Payer: Healthscope Commercial |
$128.40
|
| Rate for Payer: Healthscope Commercial |
$32.10
|
| Rate for Payer: Healthscope Whirlpool |
$93.41
|
| Rate for Payer: Healthscope Whirlpool |
$31.14
|
| Rate for Payer: Healthscope Whirlpool |
$124.55
|
| Rate for Payer: Mclaren Commercial |
$115.56
|
| Rate for Payer: Mclaren Commercial |
$86.67
|
| Rate for Payer: Mclaren Commercial |
$28.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$89.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$112.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$84.74
|
|
|
GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$428.36
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$299.85 |
| Max. Negotiated Rate |
$428.36 |
| Rate for Payer: Aetna Commercial |
$385.52
|
| Rate for Payer: Aetna Commercial |
$1,602.00
|
| Rate for Payer: ASR ASR |
$1,726.60
|
| Rate for Payer: ASR ASR |
$415.51
|
| Rate for Payer: BCBS Trust/PPO |
$1,380.03
|
| Rate for Payer: BCBS Trust/PPO |
$332.11
|
| Rate for Payer: BCN Commercial |
$1,380.03
|
| Rate for Payer: BCN Commercial |
$332.11
|
| Rate for Payer: Cash Price |
$1,424.00
|
| Rate for Payer: Cash Price |
$342.69
|
| Rate for Payer: Cofinity Commercial |
$402.66
|
| Rate for Payer: Cofinity Commercial |
$1,673.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,424.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.69
|
| Rate for Payer: Healthscope Commercial |
$428.36
|
| Rate for Payer: Healthscope Commercial |
$1,780.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,726.60
|
| Rate for Payer: Healthscope Whirlpool |
$415.51
|
| Rate for Payer: Mclaren Commercial |
$385.52
|
| Rate for Payer: Mclaren Commercial |
$1,602.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,513.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,246.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,566.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$376.96
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$1,080.00
|
| Rate for Payer: ASR ASR |
$1,164.00
|
| Rate for Payer: BCBS Trust/PPO |
$930.36
|
| Rate for Payer: BCN Commercial |
$930.36
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Cofinity Commercial |
$1,128.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$960.00
|
| Rate for Payer: Healthscope Commercial |
$1,200.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,164.00
|
| Rate for Payer: Mclaren Commercial |
$1,080.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,020.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$840.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,056.00
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$631.72
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$442.20 |
| Max. Negotiated Rate |
$631.72 |
| Rate for Payer: Aetna Commercial |
$568.55
|
| Rate for Payer: ASR ASR |
$612.77
|
| Rate for Payer: BCBS Trust/PPO |
$489.77
|
| Rate for Payer: BCN Commercial |
$489.77
|
| Rate for Payer: Cash Price |
$505.38
|
| Rate for Payer: Cofinity Commercial |
$593.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.38
|
| Rate for Payer: Healthscope Commercial |
$631.72
|
| Rate for Payer: Healthscope Whirlpool |
$612.77
|
| Rate for Payer: Mclaren Commercial |
$568.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$536.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$442.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$555.91
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH CC
|
Facility
|
IP
|
$12,631.99
|
|
|
Service Code
|
MS-DRG 378
|
| Min. Negotiated Rate |
$9,509.67 |
| Max. Negotiated Rate |
$12,631.99 |
| Rate for Payer: Aetna Medicare |
$10,010.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,512.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,512.72
|
| Rate for Payer: BCBS MAPPO |
$10,010.18
|
| Rate for Payer: BCN Medicare Advantage |
$10,010.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,010.18
|
| Rate for Payer: Humana Choice PPO Medicare |
$10,010.18
|
| Rate for Payer: Mclaren Medicare |
$10,010.18
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,510.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,511.71
|
| Rate for Payer: PACE Medicare |
$9,509.67
|
| Rate for Payer: PACE SWMI |
$10,010.18
|
| Rate for Payer: PHP Commercial |
$11,011.20
|
| Rate for Payer: PHP Medicare Advantage |
$10,010.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,631.99
|
| Rate for Payer: Priority Health Medicare |
$10,010.18
|
| Rate for Payer: Priority Health Narrow Network |
$10,105.59
|
| Rate for Payer: Railroad Medicare Medicare |
$10,010.18
|
| Rate for Payer: UHC Medicare Advantage |
$10,310.49
|
| Rate for Payer: VA VA |
$10,010.18
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH MCC
|
Facility
|
IP
|
$22,987.45
|
|
|
Service Code
|
MS-DRG 377
|
| Min. Negotiated Rate |
$15,996.42 |
| Max. Negotiated Rate |
$22,987.45 |
| Rate for Payer: Aetna Medicare |
$16,838.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,047.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,047.92
|
| Rate for Payer: BCBS MAPPO |
$16,838.34
|
| Rate for Payer: BCN Medicare Advantage |
$16,838.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,838.34
|
| Rate for Payer: Humana Choice PPO Medicare |
$16,838.34
|
| Rate for Payer: Mclaren Medicare |
$16,838.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,680.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,364.09
|
| Rate for Payer: PACE Medicare |
$15,996.42
|
| Rate for Payer: PACE SWMI |
$16,838.34
|
| Rate for Payer: PHP Commercial |
$18,522.17
|
| Rate for Payer: PHP Medicare Advantage |
$16,838.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,987.45
|
| Rate for Payer: Priority Health Medicare |
$16,838.34
|
| Rate for Payer: Priority Health Narrow Network |
$18,389.96
|
| Rate for Payer: Railroad Medicare Medicare |
$16,838.34
|
| Rate for Payer: UHC Medicare Advantage |
$17,343.49
|
| Rate for Payer: VA VA |
$16,838.34
|
|
|
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC
|
Facility
|
IP
|
$8,802.32
|
|
|
Service Code
|
MS-DRG 379
|
| Min. Negotiated Rate |
$6,504.23 |
| Max. Negotiated Rate |
$8,802.32 |
| Rate for Payer: Aetna Medicare |
$7,041.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,802.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,802.32
|
| Rate for Payer: BCBS MAPPO |
$7,041.86
|
| Rate for Payer: BCN Medicare Advantage |
$7,041.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,041.86
|
| Rate for Payer: Humana Choice PPO Medicare |
$7,041.86
|
| Rate for Payer: Mclaren Medicare |
$7,041.86
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,393.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,098.14
|
| Rate for Payer: PACE Medicare |
$6,689.77
|
| Rate for Payer: PACE SWMI |
$7,041.86
|
| Rate for Payer: PHP Commercial |
$7,746.05
|
| Rate for Payer: PHP Medicare Advantage |
$7,041.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,130.29
|
| Rate for Payer: Priority Health Medicare |
$7,041.86
|
| Rate for Payer: Priority Health Narrow Network |
$6,504.23
|
| Rate for Payer: Railroad Medicare Medicare |
$7,041.86
|
| Rate for Payer: UHC Medicare Advantage |
$7,253.12
|
| Rate for Payer: VA VA |
$7,041.86
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH CC
|
Facility
|
IP
|
$10,529.48
|
|
|
Service Code
|
MS-DRG 389
|
| Min. Negotiated Rate |
$8,002.40 |
| Max. Negotiated Rate |
$10,529.48 |
| Rate for Payer: Aetna Medicare |
$8,423.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,529.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,529.48
|
| Rate for Payer: BCBS MAPPO |
$8,423.58
|
| Rate for Payer: BCN Medicare Advantage |
$8,423.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,423.58
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,423.58
|
| Rate for Payer: Mclaren Medicare |
$8,423.58
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,844.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,687.12
|
| Rate for Payer: PACE Medicare |
$8,002.40
|
| Rate for Payer: PACE SWMI |
$8,423.58
|
| Rate for Payer: PHP Commercial |
$9,265.94
|
| Rate for Payer: PHP Medicare Advantage |
$8,423.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,225.78
|
| Rate for Payer: Priority Health Medicare |
$8,423.58
|
| Rate for Payer: Priority Health Narrow Network |
$8,180.62
|
| Rate for Payer: Railroad Medicare Medicare |
$8,423.58
|
| Rate for Payer: UHC Medicare Advantage |
$8,676.29
|
| Rate for Payer: VA VA |
$8,423.58
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH MCC
|
Facility
|
IP
|
$18,662.94
|
|
|
Service Code
|
MS-DRG 388
|
| Min. Negotiated Rate |
$13,287.51 |
| Max. Negotiated Rate |
$18,662.94 |
| Rate for Payer: Aetna Medicare |
$13,986.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,483.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,483.56
|
| Rate for Payer: BCBS MAPPO |
$13,986.85
|
| Rate for Payer: BCN Medicare Advantage |
$13,986.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,986.85
|
| Rate for Payer: Humana Choice PPO Medicare |
$13,986.85
|
| Rate for Payer: Mclaren Medicare |
$13,986.85
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,686.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,084.88
|
| Rate for Payer: PACE Medicare |
$13,287.51
|
| Rate for Payer: PACE SWMI |
$13,986.85
|
| Rate for Payer: PHP Commercial |
$15,385.54
|
| Rate for Payer: PHP Medicare Advantage |
$13,986.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,662.94
|
| Rate for Payer: Priority Health Medicare |
$13,986.85
|
| Rate for Payer: Priority Health Narrow Network |
$14,930.35
|
| Rate for Payer: Railroad Medicare Medicare |
$13,986.85
|
| Rate for Payer: UHC Medicare Advantage |
$14,406.46
|
| Rate for Payer: VA VA |
$13,986.85
|
|
|
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC
|
Facility
|
IP
|
$8,017.06
|
|
|
Service Code
|
MS-DRG 390
|
| Min. Negotiated Rate |
$5,742.05 |
| Max. Negotiated Rate |
$8,017.06 |
| Rate for Payer: Aetna Medicare |
$6,413.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,017.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,017.06
|
| Rate for Payer: BCBS MAPPO |
$6,413.65
|
| Rate for Payer: BCN Medicare Advantage |
$6,413.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,413.65
|
| Rate for Payer: Humana Choice PPO Medicare |
$6,413.65
|
| Rate for Payer: Mclaren Medicare |
$6,413.65
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,734.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,375.70
|
| Rate for Payer: PACE Medicare |
$6,092.97
|
| Rate for Payer: PACE SWMI |
$6,413.65
|
| Rate for Payer: PHP Commercial |
$7,055.02
|
| Rate for Payer: PHP Medicare Advantage |
$6,413.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7,177.56
|
| Rate for Payer: Priority Health Medicare |
$6,413.65
|
| Rate for Payer: Priority Health Narrow Network |
$5,742.05
|
| Rate for Payer: Railroad Medicare Medicare |
$6,413.65
|
| Rate for Payer: UHC Medicare Advantage |
$6,606.06
|
| Rate for Payer: VA VA |
$6,413.65
|
|
|
GAUZE BANDAGE 1/2" X 5 YARD
|
Facility
|
IP
|
$12.65
|
|
|
Service Code
|
NDC 8080763200
|
| Hospital Charge Code |
111441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.86 |
| Max. Negotiated Rate |
$12.65 |
| Rate for Payer: Aetna Commercial |
$11.38
|
| Rate for Payer: ASR ASR |
$12.27
|
| Rate for Payer: BCBS Trust/PPO |
$9.81
|
| Rate for Payer: BCN Commercial |
$9.81
|
| Rate for Payer: Cash Price |
$10.12
|
| Rate for Payer: Cofinity Commercial |
$11.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.12
|
| Rate for Payer: Healthscope Commercial |
$12.65
|
| Rate for Payer: Healthscope Whirlpool |
$12.27
|
| Rate for Payer: Mclaren Commercial |
$11.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.13
|
|
|
GAUZE BANDAGE 1/4" X 5 YARD
|
Facility
|
IP
|
$12.77
|
|
|
Service Code
|
NDC 8080763100
|
| Hospital Charge Code |
111543
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.94 |
| Max. Negotiated Rate |
$12.77 |
| Rate for Payer: Aetna Commercial |
$11.49
|
| Rate for Payer: ASR ASR |
$12.39
|
| Rate for Payer: BCBS Trust/PPO |
$9.90
|
| Rate for Payer: BCN Commercial |
$9.90
|
| Rate for Payer: Cash Price |
$10.21
|
| Rate for Payer: Cofinity Commercial |
$12.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.22
|
| Rate for Payer: Healthscope Commercial |
$12.77
|
| Rate for Payer: Healthscope Whirlpool |
$12.39
|
| Rate for Payer: Mclaren Commercial |
$11.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.24
|
|
|
GAUZE BANDAGE 1" X 5 YARD
|
Facility
|
IP
|
$15.69
|
|
|
Service Code
|
NDC 8080763300
|
| Hospital Charge Code |
111451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$15.69 |
| Rate for Payer: Aetna Commercial |
$14.12
|
| Rate for Payer: ASR ASR |
$15.22
|
| Rate for Payer: BCBS Trust/PPO |
$12.16
|
| Rate for Payer: BCN Commercial |
$12.16
|
| Rate for Payer: Cash Price |
$12.55
|
| Rate for Payer: Cofinity Commercial |
$14.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.55
|
| Rate for Payer: Healthscope Commercial |
$15.69
|
| Rate for Payer: Healthscope Whirlpool |
$15.22
|
| Rate for Payer: Mclaren Commercial |
$14.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.81
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
IP
|
$444.22
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$310.95 |
| Max. Negotiated Rate |
$444.22 |
| Rate for Payer: Aetna Commercial |
$399.80
|
| Rate for Payer: ASR ASR |
$430.89
|
| Rate for Payer: BCBS Trust/PPO |
$344.40
|
| Rate for Payer: BCN Commercial |
$344.40
|
| Rate for Payer: Cash Price |
$355.38
|
| Rate for Payer: Cofinity Commercial |
$417.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.38
|
| Rate for Payer: Healthscope Commercial |
$444.22
|
| Rate for Payer: Healthscope Whirlpool |
$430.89
|
| Rate for Payer: Mclaren Commercial |
$399.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$377.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$310.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$390.91
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
IP
|
$270.31
|
|
|
Service Code
|
NDC 6371301972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$189.22 |
| Max. Negotiated Rate |
$270.31 |
| Rate for Payer: Aetna Commercial |
$243.28
|
| Rate for Payer: ASR ASR |
$262.20
|
| Rate for Payer: BCBS Trust/PPO |
$209.57
|
| Rate for Payer: BCN Commercial |
$209.57
|
| Rate for Payer: Cash Price |
$216.25
|
| Rate for Payer: Cofinity Commercial |
$254.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.25
|
| Rate for Payer: Healthscope Commercial |
$270.31
|
| Rate for Payer: Healthscope Whirlpool |
$262.20
|
| Rate for Payer: Mclaren Commercial |
$243.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$229.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$237.87
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
IP
|
$194.52
|
|
|
Service Code
|
NDC 0009-0315-08
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.16 |
| Max. Negotiated Rate |
$194.52 |
| Rate for Payer: Aetna Commercial |
$175.07
|
| Rate for Payer: ASR ASR |
$188.68
|
| Rate for Payer: BCBS Trust/PPO |
$150.81
|
| Rate for Payer: BCN Commercial |
$150.81
|
| Rate for Payer: Cash Price |
$155.61
|
| Rate for Payer: Cofinity Commercial |
$182.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.62
|
| Rate for Payer: Healthscope Commercial |
$194.52
|
| Rate for Payer: Healthscope Whirlpool |
$188.68
|
| Rate for Payer: Mclaren Commercial |
$175.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$171.18
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$116.24
|
|
|
Service Code
|
NDC 24208-580-60
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.37 |
| Max. Negotiated Rate |
$116.24 |
| Rate for Payer: Aetna Commercial |
$104.62
|
| Rate for Payer: ASR ASR |
$112.75
|
| Rate for Payer: BCBS Trust/PPO |
$90.12
|
| Rate for Payer: BCN Commercial |
$90.12
|
| Rate for Payer: Cash Price |
$92.99
|
| Rate for Payer: Cofinity Commercial |
$109.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.99
|
| Rate for Payer: Healthscope Commercial |
$116.24
|
| Rate for Payer: Healthscope Whirlpool |
$112.75
|
| Rate for Payer: Mclaren Commercial |
$104.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.29
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$18.76
|
|
|
Service Code
|
NDC 61314-633-05
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.13 |
| Max. Negotiated Rate |
$18.76 |
| Rate for Payer: Aetna Commercial |
$16.88
|
| Rate for Payer: ASR ASR |
$18.20
|
| Rate for Payer: BCBS Trust/PPO |
$14.54
|
| Rate for Payer: BCN Commercial |
$14.54
|
| Rate for Payer: Cash Price |
$15.01
|
| Rate for Payer: Cofinity Commercial |
$17.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.01
|
| Rate for Payer: Healthscope Commercial |
$18.76
|
| Rate for Payer: Healthscope Whirlpool |
$18.20
|
| Rate for Payer: Mclaren Commercial |
$16.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.51
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$18.23
|
|
|
Service Code
|
NDC 60758-188-05
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.76 |
| Max. Negotiated Rate |
$18.23 |
| Rate for Payer: Aetna Commercial |
$16.41
|
| Rate for Payer: ASR ASR |
$17.68
|
| Rate for Payer: BCBS Trust/PPO |
$14.13
|
| Rate for Payer: BCN Commercial |
$14.13
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Commercial |
$17.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$18.23
|
| Rate for Payer: Healthscope Whirlpool |
$17.68
|
| Rate for Payer: Mclaren Commercial |
$16.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.04
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$20.75
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$20.75 |
| Rate for Payer: Aetna Commercial |
$18.68
|
| Rate for Payer: Aetna Commercial |
$49.28
|
| Rate for Payer: Aetna Commercial |
$302.76
|
| Rate for Payer: Aetna Commercial |
$30.38
|
| Rate for Payer: ASR ASR |
$32.75
|
| Rate for Payer: ASR ASR |
$20.13
|
| Rate for Payer: ASR ASR |
$53.11
|
| Rate for Payer: ASR ASR |
$326.31
|
| Rate for Payer: BCBS Trust/PPO |
$26.17
|
| Rate for Payer: BCBS Trust/PPO |
$260.81
|
| Rate for Payer: BCBS Trust/PPO |
$42.45
|
| Rate for Payer: BCBS Trust/PPO |
$16.09
|
| Rate for Payer: BCN Commercial |
$26.17
|
| Rate for Payer: BCN Commercial |
$16.09
|
| Rate for Payer: BCN Commercial |
$260.81
|
| Rate for Payer: BCN Commercial |
$42.45
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$269.12
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$16.60
|
| Rate for Payer: Cofinity Commercial |
$51.46
|
| Rate for Payer: Cofinity Commercial |
$19.50
|
| Rate for Payer: Cofinity Commercial |
$316.22
|
| Rate for Payer: Cofinity Commercial |
$31.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.80
|
| Rate for Payer: Healthscope Commercial |
$20.75
|
| Rate for Payer: Healthscope Commercial |
$54.75
|
| Rate for Payer: Healthscope Commercial |
$336.40
|
| Rate for Payer: Healthscope Commercial |
$33.76
|
| Rate for Payer: Healthscope Whirlpool |
$32.75
|
| Rate for Payer: Healthscope Whirlpool |
$53.11
|
| Rate for Payer: Healthscope Whirlpool |
$20.13
|
| Rate for Payer: Healthscope Whirlpool |
$326.31
|
| Rate for Payer: Mclaren Commercial |
$18.68
|
| Rate for Payer: Mclaren Commercial |
$30.38
|
| Rate for Payer: Mclaren Commercial |
$302.76
|
| Rate for Payer: Mclaren Commercial |
$49.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$46.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$285.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$296.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$48.18
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$27.93
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
117665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$27.93 |
| Rate for Payer: Aetna Commercial |
$25.14
|
| Rate for Payer: ASR ASR |
$27.09
|
| Rate for Payer: BCBS Trust/PPO |
$21.65
|
| Rate for Payer: BCN Commercial |
$21.65
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Cofinity Commercial |
$26.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.34
|
| Rate for Payer: Healthscope Commercial |
$27.93
|
| Rate for Payer: Healthscope Whirlpool |
$27.09
|
| Rate for Payer: Mclaren Commercial |
$25.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.58
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$4.04
|
|
|
Service Code
|
NDC 51079-425-01
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: ASR ASR |
$3.92
|
| Rate for Payer: BCBS Trust/PPO |
$3.13
|
| Rate for Payer: BCN Commercial |
$3.13
|
| Rate for Payer: Cash Price |
$3.23
|
| Rate for Payer: Cofinity Commercial |
$3.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.23
|
| Rate for Payer: Healthscope Commercial |
$4.04
|
| Rate for Payer: Healthscope Whirlpool |
$3.92
|
| Rate for Payer: Mclaren Commercial |
$3.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.56
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$4.05
|
|
|
Service Code
|
NDC 68084-326-11
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: ASR ASR |
$3.93
|
| Rate for Payer: BCBS Trust/PPO |
$3.14
|
| Rate for Payer: BCN Commercial |
$3.14
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cofinity Commercial |
$3.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.24
|
| Rate for Payer: Healthscope Commercial |
$4.05
|
| Rate for Payer: Healthscope Whirlpool |
$3.93
|
| Rate for Payer: Mclaren Commercial |
$3.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.56
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 55111-321-01
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.28 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: ASR ASR |
$75.22
|
| Rate for Payer: BCBS Trust/PPO |
$60.12
|
| Rate for Payer: BCN Commercial |
$60.12
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$72.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$77.55
|
| Rate for Payer: Healthscope Whirlpool |
$75.22
|
| Rate for Payer: Mclaren Commercial |
$69.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.24
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 16729-002-01
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.58 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.02
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: BCBS Trust/PPO |
$63.77
|
| Rate for Payer: BCN Commercial |
$63.77
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Healthscope Whirlpool |
$79.78
|
| Rate for Payer: Mclaren Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
