|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 23900001252
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.63 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$22.36
|
| Rate for Payer: ASR ASR |
$24.09
|
| Rate for Payer: BCBS Trust/PPO |
$20.40
|
| Rate for Payer: BCN Commercial |
$20.40
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$23.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$24.09
|
| Rate for Payer: Healthscope Whirlpool |
$24.84
|
| Rate for Payer: Mclaren Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Nomi Health Commercial |
$20.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.86
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 23900001252
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$22.36
|
| Rate for Payer: Aetna Medicare |
$9.19
|
| Rate for Payer: ASR ASR |
$24.09
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: BCBS Trust/PPO |
$20.48
|
| Rate for Payer: BCN Commercial |
$20.48
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$23.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$24.09
|
| Rate for Payer: Healthscope Whirlpool |
$24.84
|
| Rate for Payer: Mclaren Commercial |
$22.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Nomi Health Commercial |
$20.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.63
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$21.76
|
| Rate for Payer: Priority Health Narrow Network |
$17.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.86
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 904676130
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$9.45 |
| Rate for Payer: Aetna Commercial |
$8.51
|
| Rate for Payer: Aetna Medicare |
$3.50
|
| Rate for Payer: ASR ASR |
$9.17
|
| Rate for Payer: BCBS Complete |
$3.78
|
| Rate for Payer: BCBS Trust/PPO |
$7.79
|
| Rate for Payer: BCN Commercial |
$7.79
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cofinity Commercial |
$8.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.56
|
| Rate for Payer: Healthscope Commercial |
$9.17
|
| Rate for Payer: Healthscope Whirlpool |
$9.45
|
| Rate for Payer: Mclaren Commercial |
$8.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.03
|
| Rate for Payer: Nomi Health Commercial |
$7.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.28
|
| Rate for Payer: Priority Health Narrow Network |
$6.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.32
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$28.30
|
|
|
Service Code
|
NDC 41100081127
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.47 |
| Max. Negotiated Rate |
$28.30 |
| Rate for Payer: Aetna Commercial |
$25.47
|
| Rate for Payer: Aetna Medicare |
$10.47
|
| Rate for Payer: ASR ASR |
$27.45
|
| Rate for Payer: BCBS Complete |
$11.32
|
| Rate for Payer: BCBS Trust/PPO |
$23.33
|
| Rate for Payer: BCN Commercial |
$23.33
|
| Rate for Payer: Cash Price |
$22.64
|
| Rate for Payer: Cofinity Commercial |
$26.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.64
|
| Rate for Payer: Healthscope Commercial |
$27.45
|
| Rate for Payer: Healthscope Whirlpool |
$28.30
|
| Rate for Payer: Mclaren Commercial |
$25.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.05
|
| Rate for Payer: Nomi Health Commercial |
$23.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$24.79
|
| Rate for Payer: Priority Health Narrow Network |
$19.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.90
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$27.14
|
|
|
Service Code
|
NDC 41100081123
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Aetna Commercial |
$24.43
|
| Rate for Payer: Aetna Medicare |
$10.04
|
| Rate for Payer: ASR ASR |
$26.33
|
| Rate for Payer: BCBS Complete |
$10.86
|
| Rate for Payer: BCBS Trust/PPO |
$22.38
|
| Rate for Payer: BCN Commercial |
$22.38
|
| Rate for Payer: Cash Price |
$21.71
|
| Rate for Payer: Cofinity Commercial |
$25.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.71
|
| Rate for Payer: Healthscope Commercial |
$26.33
|
| Rate for Payer: Healthscope Whirlpool |
$27.14
|
| Rate for Payer: Mclaren Commercial |
$24.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.07
|
| Rate for Payer: Nomi Health Commercial |
$22.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23.78
|
| Rate for Payer: Priority Health Narrow Network |
$19.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.89
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$10.71
|
|
|
Service Code
|
NDC 904743535
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna Commercial |
$9.64
|
| Rate for Payer: ASR ASR |
$10.39
|
| Rate for Payer: BCBS Trust/PPO |
$8.80
|
| Rate for Payer: BCN Commercial |
$8.80
|
| Rate for Payer: Cash Price |
$8.57
|
| Rate for Payer: Cofinity Commercial |
$10.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.57
|
| Rate for Payer: Healthscope Commercial |
$10.39
|
| Rate for Payer: Healthscope Whirlpool |
$10.71
|
| Rate for Payer: Mclaren Commercial |
$9.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.10
|
| Rate for Payer: Nomi Health Commercial |
$8.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.42
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$27.14
|
|
|
Service Code
|
NDC 41100081123
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.36 |
| Max. Negotiated Rate |
$27.14 |
| Rate for Payer: Aetna Commercial |
$24.43
|
| Rate for Payer: ASR ASR |
$26.33
|
| Rate for Payer: BCBS Trust/PPO |
$22.29
|
| Rate for Payer: BCN Commercial |
$22.29
|
| Rate for Payer: Cash Price |
$21.71
|
| Rate for Payer: Cofinity Commercial |
$25.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.71
|
| Rate for Payer: Healthscope Commercial |
$26.33
|
| Rate for Payer: Healthscope Whirlpool |
$27.14
|
| Rate for Payer: Mclaren Commercial |
$24.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.07
|
| Rate for Payer: Nomi Health Commercial |
$22.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.89
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$22.75
|
|
|
Service Code
|
NDC 50024043100
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.42 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Commercial |
$20.47
|
| Rate for Payer: Aetna Medicare |
$8.42
|
| Rate for Payer: ASR ASR |
$22.07
|
| Rate for Payer: BCBS Complete |
$9.10
|
| Rate for Payer: BCBS Trust/PPO |
$18.76
|
| Rate for Payer: BCN Commercial |
$18.76
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cofinity Commercial |
$21.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Healthscope Commercial |
$22.07
|
| Rate for Payer: Healthscope Whirlpool |
$22.75
|
| Rate for Payer: Mclaren Commercial |
$20.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.34
|
| Rate for Payer: Nomi Health Commercial |
$18.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$19.93
|
| Rate for Payer: Priority Health Narrow Network |
$15.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.02
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
IP
|
$22.75
|
|
|
Service Code
|
NDC 50024043100
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.06 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Commercial |
$20.47
|
| Rate for Payer: ASR ASR |
$22.07
|
| Rate for Payer: BCBS Trust/PPO |
$18.68
|
| Rate for Payer: BCN Commercial |
$18.68
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cofinity Commercial |
$21.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Healthscope Commercial |
$22.07
|
| Rate for Payer: Healthscope Whirlpool |
$22.75
|
| Rate for Payer: Mclaren Commercial |
$20.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.34
|
| Rate for Payer: Nomi Health Commercial |
$18.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.02
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY
|
Facility
|
OP
|
$10.71
|
|
|
Service Code
|
NDC 904743535
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna Commercial |
$9.64
|
| Rate for Payer: Aetna Medicare |
$3.96
|
| Rate for Payer: ASR ASR |
$10.39
|
| Rate for Payer: BCBS Complete |
$4.28
|
| Rate for Payer: BCBS Trust/PPO |
$8.83
|
| Rate for Payer: BCN Commercial |
$8.83
|
| Rate for Payer: Cash Price |
$8.57
|
| Rate for Payer: Cofinity Commercial |
$10.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.57
|
| Rate for Payer: Healthscope Commercial |
$10.39
|
| Rate for Payer: Healthscope Whirlpool |
$10.71
|
| Rate for Payer: Mclaren Commercial |
$9.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.10
|
| Rate for Payer: Nomi Health Commercial |
$8.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$9.38
|
| Rate for Payer: Priority Health Narrow Network |
$7.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.42
|
|
|
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION
|
Facility
|
IP
|
$13.22
|
|
|
Service Code
|
HCPCS J2590
|
| Hospital Charge Code |
5944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$13.22 |
| Rate for Payer: Aetna Commercial |
$11.90
|
| Rate for Payer: Aetna Commercial |
$22.30
|
| Rate for Payer: ASR ASR |
$24.03
|
| Rate for Payer: ASR ASR |
$12.83
|
| Rate for Payer: BCBS Trust/PPO |
$20.35
|
| Rate for Payer: BCBS Trust/PPO |
$10.86
|
| Rate for Payer: BCN Commercial |
$20.35
|
| Rate for Payer: BCN Commercial |
$10.86
|
| Rate for Payer: Cash Price |
$19.82
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Cofinity Commercial |
$23.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.58
|
| Rate for Payer: Healthscope Commercial |
$12.83
|
| Rate for Payer: Healthscope Commercial |
$24.03
|
| Rate for Payer: Healthscope Whirlpool |
$24.78
|
| Rate for Payer: Healthscope Whirlpool |
$13.22
|
| Rate for Payer: Mclaren Commercial |
$22.30
|
| Rate for Payer: Mclaren Commercial |
$11.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.24
|
| Rate for Payer: Nomi Health Commercial |
$20.32
|
| Rate for Payer: Nomi Health Commercial |
$10.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.80
|
|
|
OXYTOCIN 10 UNIT/ML INJECTION SOLUTION
|
Facility
|
OP
|
$24.78
|
|
|
Service Code
|
HCPCS J2590
|
| Hospital Charge Code |
5944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$24.78 |
| Rate for Payer: Aetna Commercial |
$22.30
|
| Rate for Payer: Aetna Commercial |
$11.90
|
| Rate for Payer: Aetna Medicare |
$4.89
|
| Rate for Payer: Aetna Medicare |
$9.17
|
| Rate for Payer: ASR ASR |
$24.03
|
| Rate for Payer: ASR ASR |
$12.83
|
| Rate for Payer: BCBS Complete |
$5.29
|
| Rate for Payer: BCBS Complete |
$9.91
|
| Rate for Payer: BCBS Trust/PPO |
$20.43
|
| Rate for Payer: BCBS Trust/PPO |
$10.90
|
| Rate for Payer: BCN Commercial |
$10.90
|
| Rate for Payer: BCN Commercial |
$20.43
|
| Rate for Payer: Cash Price |
$19.82
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cash Price |
$19.82
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Cofinity Commercial |
$23.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.58
|
| Rate for Payer: Healthscope Commercial |
$24.03
|
| Rate for Payer: Healthscope Commercial |
$12.83
|
| Rate for Payer: Healthscope Whirlpool |
$24.78
|
| Rate for Payer: Healthscope Whirlpool |
$13.22
|
| Rate for Payer: Mclaren Commercial |
$22.30
|
| Rate for Payer: Mclaren Commercial |
$11.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.06
|
| Rate for Payer: Nomi Health Commercial |
$10.84
|
| Rate for Payer: Nomi Health Commercial |
$20.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.58
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.43
|
| Rate for Payer: Priority Health Narrow Network |
$1.14
|
| Rate for Payer: Priority Health Narrow Network |
$1.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.80
|
|
|
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$59.54
|
|
|
Service Code
|
HCPCS J2430
|
| Hospital Charge Code |
32589
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.03 |
| Max. Negotiated Rate |
$59.54 |
| Rate for Payer: Aetna Commercial |
$53.59
|
| Rate for Payer: Aetna Commercial |
$34.32
|
| Rate for Payer: Aetna Medicare |
$14.11
|
| Rate for Payer: Aetna Medicare |
$22.03
|
| Rate for Payer: ASR ASR |
$57.75
|
| Rate for Payer: ASR ASR |
$36.99
|
| Rate for Payer: BCBS Complete |
$15.25
|
| Rate for Payer: BCBS Complete |
$23.82
|
| Rate for Payer: BCBS Trust/PPO |
$49.09
|
| Rate for Payer: BCBS Trust/PPO |
$31.44
|
| Rate for Payer: BCN Commercial |
$31.44
|
| Rate for Payer: BCN Commercial |
$49.09
|
| Rate for Payer: Cash Price |
$47.63
|
| Rate for Payer: Cash Price |
$30.51
|
| Rate for Payer: Cash Price |
$47.63
|
| Rate for Payer: Cash Price |
$30.51
|
| Rate for Payer: Cofinity Commercial |
$35.85
|
| Rate for Payer: Cofinity Commercial |
$55.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.51
|
| Rate for Payer: Healthscope Commercial |
$57.75
|
| Rate for Payer: Healthscope Commercial |
$36.99
|
| Rate for Payer: Healthscope Whirlpool |
$59.54
|
| Rate for Payer: Healthscope Whirlpool |
$38.14
|
| Rate for Payer: Mclaren Commercial |
$53.59
|
| Rate for Payer: Mclaren Commercial |
$34.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.61
|
| Rate for Payer: Nomi Health Commercial |
$31.27
|
| Rate for Payer: Nomi Health Commercial |
$48.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.66
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$39.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$39.84
|
| Rate for Payer: Priority Health Narrow Network |
$31.87
|
| Rate for Payer: Priority Health Narrow Network |
$31.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.40
|
|
|
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$38.14
|
|
|
Service Code
|
HCPCS J2430
|
| Hospital Charge Code |
32589
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.60 |
| Max. Negotiated Rate |
$38.14 |
| Rate for Payer: Aetna Commercial |
$34.32
|
| Rate for Payer: Aetna Commercial |
$53.59
|
| Rate for Payer: ASR ASR |
$57.75
|
| Rate for Payer: ASR ASR |
$36.99
|
| Rate for Payer: BCBS Trust/PPO |
$48.90
|
| Rate for Payer: BCBS Trust/PPO |
$31.32
|
| Rate for Payer: BCN Commercial |
$48.90
|
| Rate for Payer: BCN Commercial |
$31.32
|
| Rate for Payer: Cash Price |
$47.63
|
| Rate for Payer: Cash Price |
$30.51
|
| Rate for Payer: Cofinity Commercial |
$35.85
|
| Rate for Payer: Cofinity Commercial |
$55.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.51
|
| Rate for Payer: Healthscope Commercial |
$36.99
|
| Rate for Payer: Healthscope Commercial |
$57.75
|
| Rate for Payer: Healthscope Whirlpool |
$59.54
|
| Rate for Payer: Healthscope Whirlpool |
$38.14
|
| Rate for Payer: Mclaren Commercial |
$53.59
|
| Rate for Payer: Mclaren Commercial |
$34.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.42
|
| Rate for Payer: Nomi Health Commercial |
$48.82
|
| Rate for Payer: Nomi Health Commercial |
$31.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.40
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC
|
Facility
|
IP
|
$39,845.27
|
|
|
Service Code
|
MSDRG 406
|
| Min. Negotiated Rate |
$21,507.53 |
| Max. Negotiated Rate |
$39,845.27 |
| Rate for Payer: Aetna Medicare |
$22,639.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28,299.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28,299.39
|
| Rate for Payer: BCBS MAPPO |
$22,639.51
|
| Rate for Payer: BCN Medicare Advantage |
$22,639.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22,639.51
|
| Rate for Payer: Humana Choice PPO Medicare |
$22,639.51
|
| Rate for Payer: Mclaren Medicare |
$22,639.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23,771.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26,035.44
|
| Rate for Payer: Molina Medicare/Medicaid |
$24,903.46
|
| Rate for Payer: PACE Medicare |
$21,507.53
|
| Rate for Payer: PACE SWMI |
$22,639.51
|
| Rate for Payer: PHP Commercial |
$24,903.46
|
| Rate for Payer: PHP Medicare Advantage |
$22,639.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$39,845.27
|
| Rate for Payer: Priority Health Medicare |
$22,639.51
|
| Rate for Payer: Priority Health Narrow Network |
$31,876.21
|
| Rate for Payer: Railroad Medicare Medicare |
$22,639.51
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$22,639.51
|
| Rate for Payer: UHC Exchange |
$35,091.24
|
| Rate for Payer: UHCCP DNSP |
$22,639.51
|
| Rate for Payer: VA VA |
$22,639.51
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC
|
Facility
|
IP
|
$75,158.11
|
|
|
Service Code
|
MSDRG 405
|
| Min. Negotiated Rate |
$39,091.42 |
| Max. Negotiated Rate |
$75,158.11 |
| Rate for Payer: Aetna Medicare |
$41,148.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$51,436.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$51,436.07
|
| Rate for Payer: BCBS MAPPO |
$41,148.86
|
| Rate for Payer: BCN Medicare Advantage |
$41,148.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41,148.86
|
| Rate for Payer: Humana Choice PPO Medicare |
$41,148.86
|
| Rate for Payer: Mclaren Medicare |
$41,148.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$43,206.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47,321.19
|
| Rate for Payer: Molina Medicare/Medicaid |
$45,263.75
|
| Rate for Payer: PACE Medicare |
$39,091.42
|
| Rate for Payer: PACE SWMI |
$41,148.86
|
| Rate for Payer: PHP Commercial |
$45,263.75
|
| Rate for Payer: PHP Medicare Advantage |
$41,148.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$75,158.11
|
| Rate for Payer: Priority Health Medicare |
$41,148.86
|
| Rate for Payer: Priority Health Narrow Network |
$60,126.48
|
| Rate for Payer: Railroad Medicare Medicare |
$41,148.86
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$41,148.86
|
| Rate for Payer: UHC Exchange |
$63,780.73
|
| Rate for Payer: UHCCP DNSP |
$41,148.86
|
| Rate for Payer: VA VA |
$41,148.86
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$30,494.64
|
|
|
Service Code
|
MSDRG 407
|
| Min. Negotiated Rate |
$16,851.42 |
| Max. Negotiated Rate |
$30,494.64 |
| Rate for Payer: Aetna Medicare |
$17,738.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22,172.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22,172.92
|
| Rate for Payer: BCBS MAPPO |
$17,738.34
|
| Rate for Payer: BCN Medicare Advantage |
$17,738.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,738.34
|
| Rate for Payer: Humana Choice PPO Medicare |
$17,738.34
|
| Rate for Payer: Mclaren Medicare |
$17,738.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18,625.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20,399.09
|
| Rate for Payer: Molina Medicare/Medicaid |
$19,512.17
|
| Rate for Payer: PACE Medicare |
$16,851.42
|
| Rate for Payer: PACE SWMI |
$17,738.34
|
| Rate for Payer: PHP Commercial |
$19,512.17
|
| Rate for Payer: PHP Medicare Advantage |
$17,738.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$30,494.64
|
| Rate for Payer: Priority Health Medicare |
$17,738.34
|
| Rate for Payer: Priority Health Narrow Network |
$24,395.71
|
| Rate for Payer: Railroad Medicare Medicare |
$17,738.34
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$17,738.34
|
| Rate for Payer: UHC Exchange |
$27,494.43
|
| Rate for Payer: UHCCP DNSP |
$17,738.34
|
| Rate for Payer: VA VA |
$17,738.34
|
|
|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$98,585.51
|
|
|
Service Code
|
MSDRG 010
|
| Min. Negotiated Rate |
$50,757.01 |
| Max. Negotiated Rate |
$98,585.51 |
| Rate for Payer: Aetna Medicare |
$53,428.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66,785.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66,785.54
|
| Rate for Payer: BCBS MAPPO |
$53,428.43
|
| Rate for Payer: BCN Medicare Advantage |
$53,428.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$53,428.43
|
| Rate for Payer: Humana Choice PPO Medicare |
$53,428.43
|
| Rate for Payer: Mclaren Medicare |
$53,428.43
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$56,099.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61,442.69
|
| Rate for Payer: Molina Medicare/Medicaid |
$58,771.27
|
| Rate for Payer: PACE Medicare |
$50,757.01
|
| Rate for Payer: PACE SWMI |
$53,428.43
|
| Rate for Payer: PHP Commercial |
$58,771.27
|
| Rate for Payer: PHP Medicare Advantage |
$53,428.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$98,585.51
|
| Rate for Payer: Priority Health Medicare |
$53,428.43
|
| Rate for Payer: Priority Health Narrow Network |
$78,868.41
|
| Rate for Payer: Railroad Medicare Medicare |
$53,428.43
|
| Rate for Payer: UHCCP DNSP |
$53,428.43
|
| Rate for Payer: VA VA |
$53,428.43
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$219.96
|
|
|
Service Code
|
NDC 378668877
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.97 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna Commercial |
$197.96
|
| Rate for Payer: ASR ASR |
$213.36
|
| Rate for Payer: BCBS Trust/PPO |
$180.63
|
| Rate for Payer: BCN Commercial |
$180.63
|
| Rate for Payer: Cash Price |
$175.97
|
| Rate for Payer: Cofinity Commercial |
$206.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.97
|
| Rate for Payer: Healthscope Commercial |
$213.36
|
| Rate for Payer: Healthscope Whirlpool |
$219.96
|
| Rate for Payer: Mclaren Commercial |
$197.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.97
|
| Rate for Payer: Nomi Health Commercial |
$180.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$193.56
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$219.96
|
|
|
Service Code
|
NDC 378668877
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.39 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna Commercial |
$197.96
|
| Rate for Payer: Aetna Medicare |
$81.39
|
| Rate for Payer: ASR ASR |
$213.36
|
| Rate for Payer: BCBS Complete |
$87.98
|
| Rate for Payer: BCBS Trust/PPO |
$181.36
|
| Rate for Payer: BCN Commercial |
$181.36
|
| Rate for Payer: Cash Price |
$175.97
|
| Rate for Payer: Cofinity Commercial |
$206.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.97
|
| Rate for Payer: Healthscope Commercial |
$213.36
|
| Rate for Payer: Healthscope Whirlpool |
$219.96
|
| Rate for Payer: Mclaren Commercial |
$197.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$175.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.97
|
| Rate for Payer: Nomi Health Commercial |
$180.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.97
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$192.73
|
| Rate for Payer: Priority Health Narrow Network |
$154.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$193.56
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$126.83
|
|
|
Service Code
|
NDC 50268058515
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.12 |
| Max. Negotiated Rate |
$126.83 |
| Rate for Payer: Aetna Commercial |
$114.14
|
| Rate for Payer: ASR ASR |
$123.02
|
| Rate for Payer: BCBS Trust/PPO |
$104.15
|
| Rate for Payer: BCN Commercial |
$104.15
|
| Rate for Payer: Cash Price |
$101.46
|
| Rate for Payer: Cofinity Commercial |
$119.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.46
|
| Rate for Payer: Healthscope Commercial |
$123.02
|
| Rate for Payer: Healthscope Whirlpool |
$126.83
|
| Rate for Payer: Mclaren Commercial |
$114.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.80
|
| Rate for Payer: Nomi Health Commercial |
$104.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$95.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$111.61
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$2.54
|
|
|
Service Code
|
NDC 50268058511
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: Aetna Medicare |
$0.94
|
| Rate for Payer: ASR ASR |
$2.46
|
| Rate for Payer: BCBS Complete |
$1.01
|
| Rate for Payer: BCBS Trust/PPO |
$2.09
|
| Rate for Payer: BCN Commercial |
$2.09
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cofinity Commercial |
$2.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.03
|
| Rate for Payer: Healthscope Commercial |
$2.46
|
| Rate for Payer: Healthscope Whirlpool |
$2.54
|
| Rate for Payer: Mclaren Commercial |
$2.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.16
|
| Rate for Payer: Nomi Health Commercial |
$2.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.22
|
| Rate for Payer: Priority Health Narrow Network |
$1.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.23
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$126.83
|
|
|
Service Code
|
NDC 50268058515
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.93 |
| Max. Negotiated Rate |
$126.83 |
| Rate for Payer: Aetna Commercial |
$114.14
|
| Rate for Payer: Aetna Medicare |
$46.93
|
| Rate for Payer: ASR ASR |
$123.02
|
| Rate for Payer: BCBS Complete |
$50.73
|
| Rate for Payer: BCBS Trust/PPO |
$104.57
|
| Rate for Payer: BCN Commercial |
$104.57
|
| Rate for Payer: Cash Price |
$101.46
|
| Rate for Payer: Cofinity Commercial |
$119.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.46
|
| Rate for Payer: Healthscope Commercial |
$123.02
|
| Rate for Payer: Healthscope Whirlpool |
$126.83
|
| Rate for Payer: Mclaren Commercial |
$114.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$101.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.80
|
| Rate for Payer: Nomi Health Commercial |
$104.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$95.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$111.12
|
| Rate for Payer: Priority Health Narrow Network |
$88.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$111.61
|
|
|
PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.54
|
|
|
Service Code
|
NDC 50268058511
|
| Hospital Charge Code |
26224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: ASR ASR |
$2.46
|
| Rate for Payer: BCBS Trust/PPO |
$2.08
|
| Rate for Payer: BCN Commercial |
$2.08
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cofinity Commercial |
$2.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.03
|
| Rate for Payer: Healthscope Commercial |
$2.46
|
| Rate for Payer: Healthscope Whirlpool |
$2.54
|
| Rate for Payer: Mclaren Commercial |
$2.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.16
|
| Rate for Payer: Nomi Health Commercial |
$2.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.23
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.27
|
|
|
Service Code
|
HCPCS J2471
|
| Hospital Charge Code |
26226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$19.27 |
| Rate for Payer: Aetna Commercial |
$17.34
|
| Rate for Payer: Aetna Medicare |
$7.13
|
| Rate for Payer: ASR ASR |
$18.69
|
| Rate for Payer: BCBS Complete |
$7.71
|
| Rate for Payer: BCBS Trust/PPO |
$15.89
|
| Rate for Payer: BCN Commercial |
$15.89
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: Cofinity Commercial |
$18.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.42
|
| Rate for Payer: Healthscope Commercial |
$18.69
|
| Rate for Payer: Healthscope Whirlpool |
$19.27
|
| Rate for Payer: Mclaren Commercial |
$17.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.38
|
| Rate for Payer: Nomi Health Commercial |
$15.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.57
|
| Rate for Payer: Priority Health Narrow Network |
$2.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.96
|
|
