|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$998.34
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
112201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$998.34 |
| Rate for Payer: Aetna Commercial |
$898.51
|
| Rate for Payer: Aetna Medicare |
$26.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33.52
|
| Rate for Payer: ASR ASR |
$968.39
|
| Rate for Payer: ASR Commercial |
$968.39
|
| Rate for Payer: BCBS Complete |
$15.09
|
| Rate for Payer: BCBS MAPPO |
$26.82
|
| Rate for Payer: BCBS Trust/PPO |
$817.54
|
| Rate for Payer: BCN Commercial |
$774.01
|
| Rate for Payer: BCN Medicare Advantage |
$26.82
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cofinity Commercial |
$938.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26.82
|
| Rate for Payer: Healthscope Commercial |
$998.34
|
| Rate for Payer: Healthscope Whirlpool |
$968.39
|
| Rate for Payer: Humana Choice PPO Medicare |
$26.82
|
| Rate for Payer: Mclaren Commercial |
$898.51
|
| Rate for Payer: Mclaren Medicaid |
$14.38
|
| Rate for Payer: Mclaren Medicare |
$26.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.16
|
| Rate for Payer: Meridian Medicaid |
$15.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.59
|
| Rate for Payer: Nomi Health Commercial |
$818.64
|
| Rate for Payer: PACE Medicare |
$25.48
|
| Rate for Payer: PACE SWMI |
$26.82
|
| Rate for Payer: PHP Commercial |
$29.50
|
| Rate for Payer: PHP Medicaid |
$14.38
|
| Rate for Payer: PHP Medicare Advantage |
$26.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$14.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.00
|
| Rate for Payer: Priority Health Medicare |
$26.82
|
| Rate for Payer: Priority Health Narrow Network |
$22.40
|
| Rate for Payer: Railroad Medicare Medicare |
$26.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$878.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$26.82
|
| Rate for Payer: UHC Exchange |
$41.57
|
| Rate for Payer: UHC Medicare Advantage |
$26.82
|
| Rate for Payer: UHCCP DNSP |
$26.82
|
| Rate for Payer: UHCCP Medicaid |
$14.38
|
| Rate for Payer: VA VA |
$26.82
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$998.34
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
112201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$648.92 |
| Max. Negotiated Rate |
$998.34 |
| Rate for Payer: Aetna Commercial |
$898.51
|
| Rate for Payer: ASR ASR |
$968.39
|
| Rate for Payer: ASR Commercial |
$968.39
|
| Rate for Payer: BCBS Trust/PPO |
$813.55
|
| Rate for Payer: BCN Commercial |
$774.01
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cofinity Commercial |
$938.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.67
|
| Rate for Payer: Healthscope Commercial |
$998.34
|
| Rate for Payer: Healthscope Whirlpool |
$968.39
|
| Rate for Payer: Mclaren Commercial |
$898.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.59
|
| Rate for Payer: Nomi Health Commercial |
$818.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$878.54
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE CUSTOM
|
Facility
|
IP
|
$998.34
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
301789
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$648.92 |
| Max. Negotiated Rate |
$998.34 |
| Rate for Payer: Aetna Commercial |
$898.51
|
| Rate for Payer: ASR ASR |
$968.39
|
| Rate for Payer: ASR Commercial |
$968.39
|
| Rate for Payer: BCBS Trust/PPO |
$813.55
|
| Rate for Payer: BCN Commercial |
$774.01
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cofinity Commercial |
$938.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.67
|
| Rate for Payer: Healthscope Commercial |
$998.34
|
| Rate for Payer: Healthscope Whirlpool |
$968.39
|
| Rate for Payer: Mclaren Commercial |
$898.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.59
|
| Rate for Payer: Nomi Health Commercial |
$818.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$878.54
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE CUSTOM
|
Facility
|
OP
|
$998.34
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
301789
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$998.34 |
| Rate for Payer: Aetna Commercial |
$898.51
|
| Rate for Payer: Aetna Medicare |
$26.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33.52
|
| Rate for Payer: ASR ASR |
$968.39
|
| Rate for Payer: ASR Commercial |
$968.39
|
| Rate for Payer: BCBS Complete |
$15.09
|
| Rate for Payer: BCBS MAPPO |
$26.82
|
| Rate for Payer: BCBS Trust/PPO |
$817.54
|
| Rate for Payer: BCN Commercial |
$774.01
|
| Rate for Payer: BCN Medicare Advantage |
$26.82
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cash Price |
$798.67
|
| Rate for Payer: Cofinity Commercial |
$938.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26.82
|
| Rate for Payer: Healthscope Commercial |
$998.34
|
| Rate for Payer: Healthscope Whirlpool |
$968.39
|
| Rate for Payer: Humana Choice PPO Medicare |
$26.82
|
| Rate for Payer: Mclaren Commercial |
$898.51
|
| Rate for Payer: Mclaren Medicaid |
$14.38
|
| Rate for Payer: Mclaren Medicare |
$26.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.16
|
| Rate for Payer: Meridian Medicaid |
$15.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$848.59
|
| Rate for Payer: Nomi Health Commercial |
$818.64
|
| Rate for Payer: PACE Medicare |
$25.48
|
| Rate for Payer: PACE SWMI |
$26.82
|
| Rate for Payer: PHP Commercial |
$29.50
|
| Rate for Payer: PHP Medicaid |
$14.38
|
| Rate for Payer: PHP Medicare Advantage |
$26.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$14.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$648.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.00
|
| Rate for Payer: Priority Health Medicare |
$26.82
|
| Rate for Payer: Priority Health Narrow Network |
$22.40
|
| Rate for Payer: Railroad Medicare Medicare |
$26.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$878.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$26.82
|
| Rate for Payer: UHC Exchange |
$41.57
|
| Rate for Payer: UHC Medicare Advantage |
$26.82
|
| Rate for Payer: UHCCP DNSP |
$26.82
|
| Rate for Payer: UHCCP Medicaid |
$14.38
|
| Rate for Payer: VA VA |
$26.82
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET
|
Facility
|
IP
|
$176.25
|
|
|
Service Code
|
NDC 57237004001
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.56 |
| Max. Negotiated Rate |
$176.25 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: ASR ASR |
$170.96
|
| Rate for Payer: ASR Commercial |
$170.96
|
| Rate for Payer: BCBS Trust/PPO |
$143.63
|
| Rate for Payer: BCN Commercial |
$136.65
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cofinity Commercial |
$165.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.00
|
| Rate for Payer: Healthscope Commercial |
$176.25
|
| Rate for Payer: Healthscope Whirlpool |
$170.96
|
| Rate for Payer: Mclaren Commercial |
$158.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.81
|
| Rate for Payer: Nomi Health Commercial |
$144.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$155.10
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 65862017501
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.04 |
| Max. Negotiated Rate |
$173.90 |
| Rate for Payer: Aetna Commercial |
$156.51
|
| Rate for Payer: ASR ASR |
$168.68
|
| Rate for Payer: ASR Commercial |
$168.68
|
| Rate for Payer: BCBS Trust/PPO |
$141.71
|
| 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 Commercial |
$147.82
|
| Rate for Payer: Nomi Health Commercial |
$142.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$153.03
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET
|
Facility
|
OP
|
$173.90
|
|
|
Service Code
|
NDC 65862017501
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.56 |
| Max. Negotiated Rate |
$173.90 |
| Rate for Payer: Aetna Commercial |
$156.51
|
| Rate for Payer: Aetna Medicare |
$86.95
|
| Rate for Payer: ASR ASR |
$168.68
|
| Rate for Payer: ASR Commercial |
$168.68
|
| Rate for Payer: BCBS Complete |
$69.56
|
| Rate for Payer: BCBS Trust/PPO |
$142.41
|
| 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 Commercial |
$147.82
|
| Rate for Payer: Nomi Health Commercial |
$142.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$152.37
|
| Rate for Payer: Priority Health Narrow Network |
$121.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$153.03
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET
|
Facility
|
OP
|
$176.25
|
|
|
Service Code
|
NDC 57237004001
|
| Hospital Charge Code |
6092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.50 |
| Max. Negotiated Rate |
$176.25 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Aetna Medicare |
$88.12
|
| Rate for Payer: ASR ASR |
$170.96
|
| Rate for Payer: ASR Commercial |
$170.96
|
| Rate for Payer: BCBS Complete |
$70.50
|
| Rate for Payer: BCBS Trust/PPO |
$144.33
|
| Rate for Payer: BCN Commercial |
$136.65
|
| Rate for Payer: Cash Price |
$141.00
|
| Rate for Payer: Cofinity Commercial |
$165.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.00
|
| Rate for Payer: Healthscope Commercial |
$176.25
|
| Rate for Payer: Healthscope Whirlpool |
$170.96
|
| Rate for Payer: Mclaren Commercial |
$158.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.81
|
| Rate for Payer: Nomi Health Commercial |
$144.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$154.43
|
| Rate for Payer: Priority Health Narrow Network |
$123.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$155.10
|
|
|
PEN NEEDLE, DIABETIC, SAFETY 30 GAUGE X 1/3" (8MM)
|
Facility
|
IP
|
$300.81
|
|
|
Service Code
|
NDC 00169185275
|
| Hospital Charge Code |
117156
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.53 |
| Max. Negotiated Rate |
$300.81 |
| Rate for Payer: Aetna Commercial |
$270.73
|
| Rate for Payer: ASR ASR |
$291.79
|
| Rate for Payer: ASR Commercial |
$291.79
|
| Rate for Payer: BCBS Trust/PPO |
$245.13
|
| Rate for Payer: BCN Commercial |
$233.22
|
| Rate for Payer: Cash Price |
$240.65
|
| Rate for Payer: Cofinity Commercial |
$282.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.65
|
| Rate for Payer: Healthscope Commercial |
$300.81
|
| Rate for Payer: Healthscope Whirlpool |
$291.79
|
| Rate for Payer: Mclaren Commercial |
$270.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.69
|
| Rate for Payer: Nomi Health Commercial |
$246.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$264.71
|
|
|
PEN NEEDLE, DIABETIC, SAFETY 30 GAUGE X 1/3" (8MM)
|
Facility
|
OP
|
$300.81
|
|
|
Service Code
|
NDC 00169185275
|
| Hospital Charge Code |
117156
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.32 |
| Max. Negotiated Rate |
$300.81 |
| Rate for Payer: Aetna Commercial |
$270.73
|
| Rate for Payer: Aetna Medicare |
$150.40
|
| Rate for Payer: ASR ASR |
$291.79
|
| Rate for Payer: ASR Commercial |
$291.79
|
| Rate for Payer: BCBS Complete |
$120.32
|
| Rate for Payer: BCBS Trust/PPO |
$246.33
|
| Rate for Payer: BCN Commercial |
$233.22
|
| Rate for Payer: Cash Price |
$240.65
|
| Rate for Payer: Cofinity Commercial |
$282.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.65
|
| Rate for Payer: Healthscope Commercial |
$300.81
|
| Rate for Payer: Healthscope Whirlpool |
$291.79
|
| Rate for Payer: Mclaren Commercial |
$270.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.69
|
| Rate for Payer: Nomi Health Commercial |
$246.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.57
|
| Rate for Payer: Priority Health Narrow Network |
$210.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$264.71
|
|
|
PEPTAMEN AF BOLUS FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
150863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF BOLUS FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
150863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF BOLUS FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
150863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF BOLUS FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
150863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CONTINUOUS FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
168955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CONTINUOUS FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
168955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CONTINUOUS FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
168955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CONTINUOUS FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
168955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CYCLIC FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
200079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CYCLIC FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
200079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CYCLIC FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
200079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CYCLIC FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
200079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF INTERMITTENT FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
200078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF INTERMITTENT FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
200078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF INTERMITTENT FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
200078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
