|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$61.18
|
|
|
Service Code
|
NDC 338002302
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$61.18 |
| Rate for Payer: Aetna Commercial |
$55.06
|
| Rate for Payer: ASR ASR |
$59.34
|
| Rate for Payer: BCBS Trust/PPO |
$50.24
|
| Rate for Payer: BCN Commercial |
$50.24
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$57.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$59.34
|
| Rate for Payer: Healthscope Whirlpool |
$61.18
|
| Rate for Payer: Mclaren Commercial |
$55.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.00
|
| Rate for Payer: Nomi Health Commercial |
$50.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$53.84
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 338002304
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.44 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$62.93
|
| Rate for Payer: ASR ASR |
$67.82
|
| Rate for Payer: BCBS Trust/PPO |
$57.42
|
| Rate for Payer: BCN Commercial |
$57.42
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$65.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$67.82
|
| Rate for Payer: Healthscope Whirlpool |
$69.92
|
| Rate for Payer: Mclaren Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Nomi Health Commercial |
$57.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.53
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$79.75
|
|
|
Service Code
|
NDC 990793002
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.51 |
| Max. Negotiated Rate |
$79.75 |
| Rate for Payer: Aetna Commercial |
$71.78
|
| Rate for Payer: Aetna Medicare |
$29.51
|
| Rate for Payer: ASR ASR |
$77.36
|
| Rate for Payer: BCBS Complete |
$31.90
|
| Rate for Payer: BCBS Trust/PPO |
$65.75
|
| Rate for Payer: BCN Commercial |
$65.75
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Commercial |
$74.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Healthscope Commercial |
$77.36
|
| Rate for Payer: Healthscope Whirlpool |
$79.75
|
| Rate for Payer: Mclaren Commercial |
$71.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Nomi Health Commercial |
$65.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$69.88
|
| Rate for Payer: Priority Health Narrow Network |
$55.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.18
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$61.18
|
|
|
Service Code
|
NDC 338002302
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.64 |
| Max. Negotiated Rate |
$61.18 |
| Rate for Payer: Aetna Commercial |
$55.06
|
| Rate for Payer: Aetna Medicare |
$22.64
|
| Rate for Payer: ASR ASR |
$59.34
|
| Rate for Payer: BCBS Complete |
$24.47
|
| Rate for Payer: BCBS Trust/PPO |
$50.44
|
| Rate for Payer: BCN Commercial |
$50.44
|
| Rate for Payer: Cash Price |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$57.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.94
|
| Rate for Payer: Healthscope Commercial |
$59.34
|
| Rate for Payer: Healthscope Whirlpool |
$61.18
|
| Rate for Payer: Mclaren Commercial |
$55.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.00
|
| Rate for Payer: Nomi Health Commercial |
$50.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.88
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$53.61
|
| Rate for Payer: Priority Health Narrow Network |
$42.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$53.84
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION MAXIMUM RATE 250 MR
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
NDC 338002304
|
| Hospital Charge Code |
300148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$62.93
|
| Rate for Payer: Aetna Medicare |
$25.87
|
| Rate for Payer: ASR ASR |
$67.82
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$57.65
|
| Rate for Payer: BCN Commercial |
$57.65
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$65.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$67.82
|
| Rate for Payer: Healthscope Whirlpool |
$69.92
|
| Rate for Payer: Mclaren Commercial |
$62.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Nomi Health Commercial |
$57.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$61.26
|
| Rate for Payer: Priority Health Narrow Network |
$49.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.53
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION MAXIMUM RATE 250 MR
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
NDC 338002304
|
| Hospital Charge Code |
300148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.44 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$62.93
|
| Rate for Payer: ASR ASR |
$67.82
|
| Rate for Payer: BCBS Trust/PPO |
$57.42
|
| Rate for Payer: BCN Commercial |
$57.42
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$65.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$67.82
|
| Rate for Payer: Healthscope Whirlpool |
$69.92
|
| Rate for Payer: Mclaren Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Nomi Health Commercial |
$57.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.53
|
|
|
DEXTROSE 10 % IV BOLUS
|
Facility
|
OP
|
$63.80
|
|
|
Service Code
|
NDC 264752020
|
| Hospital Charge Code |
400302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.61 |
| Max. Negotiated Rate |
$63.80 |
| Rate for Payer: Aetna Commercial |
$57.42
|
| Rate for Payer: Aetna Medicare |
$23.61
|
| Rate for Payer: ASR ASR |
$61.89
|
| Rate for Payer: BCBS Complete |
$25.52
|
| Rate for Payer: BCBS Trust/PPO |
$52.60
|
| Rate for Payer: BCN Commercial |
$52.60
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Commercial |
$59.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$61.89
|
| Rate for Payer: Healthscope Whirlpool |
$63.80
|
| Rate for Payer: Mclaren Commercial |
$57.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: Nomi Health Commercial |
$52.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$55.90
|
| Rate for Payer: Priority Health Narrow Network |
$44.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.14
|
|
|
DEXTROSE 10 % IV BOLUS
|
Facility
|
IP
|
$63.80
|
|
|
Service Code
|
NDC 264752020
|
| Hospital Charge Code |
400302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.85 |
| Max. Negotiated Rate |
$63.80 |
| Rate for Payer: Aetna Commercial |
$57.42
|
| Rate for Payer: ASR ASR |
$61.89
|
| Rate for Payer: BCBS Trust/PPO |
$52.39
|
| Rate for Payer: BCN Commercial |
$52.39
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cofinity Commercial |
$59.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.04
|
| Rate for Payer: Healthscope Commercial |
$61.89
|
| Rate for Payer: Healthscope Whirlpool |
$63.80
|
| Rate for Payer: Mclaren Commercial |
$57.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.23
|
| Rate for Payer: Nomi Health Commercial |
$52.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.14
|
|
|
DEXTROSE 15 GRAM/32 ML ORAL GEL PACKET
|
Facility
|
IP
|
$42.98
|
|
|
Service Code
|
NDC 21292000441
|
| Hospital Charge Code |
185468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.23 |
| Max. Negotiated Rate |
$42.98 |
| Rate for Payer: Aetna Commercial |
$38.68
|
| Rate for Payer: ASR ASR |
$41.69
|
| Rate for Payer: BCBS Trust/PPO |
$35.30
|
| Rate for Payer: BCN Commercial |
$35.30
|
| Rate for Payer: Cash Price |
$34.38
|
| Rate for Payer: Cofinity Commercial |
$40.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.38
|
| Rate for Payer: Healthscope Commercial |
$41.69
|
| Rate for Payer: Healthscope Whirlpool |
$42.98
|
| Rate for Payer: Mclaren Commercial |
$38.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.53
|
| Rate for Payer: Nomi Health Commercial |
$35.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.82
|
|
|
DEXTROSE 15 GRAM/32 ML ORAL GEL PACKET
|
Facility
|
OP
|
$42.98
|
|
|
Service Code
|
NDC 21292000441
|
| Hospital Charge Code |
185468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$42.98 |
| Rate for Payer: Aetna Commercial |
$38.68
|
| Rate for Payer: Aetna Medicare |
$15.90
|
| Rate for Payer: ASR ASR |
$41.69
|
| Rate for Payer: BCBS Complete |
$17.19
|
| Rate for Payer: BCBS Trust/PPO |
$35.44
|
| Rate for Payer: BCN Commercial |
$35.44
|
| Rate for Payer: Cash Price |
$34.38
|
| Rate for Payer: Cofinity Commercial |
$40.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.38
|
| Rate for Payer: Healthscope Commercial |
$41.69
|
| Rate for Payer: Healthscope Whirlpool |
$42.98
|
| Rate for Payer: Mclaren Commercial |
$38.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.53
|
| Rate for Payer: Nomi Health Commercial |
$35.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.23
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$37.66
|
| Rate for Payer: Priority Health Narrow Network |
$30.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.82
|
|
|
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$89.40
|
|
|
Service Code
|
NDC 409177510
|
| Hospital Charge Code |
2361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.05 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: Aetna Commercial |
$80.46
|
| Rate for Payer: ASR ASR |
$86.72
|
| Rate for Payer: BCBS Trust/PPO |
$73.42
|
| Rate for Payer: BCN Commercial |
$73.42
|
| Rate for Payer: Cash Price |
$71.52
|
| Rate for Payer: Cofinity Commercial |
$84.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.52
|
| Rate for Payer: Healthscope Commercial |
$86.72
|
| Rate for Payer: Healthscope Whirlpool |
$89.40
|
| Rate for Payer: Mclaren Commercial |
$80.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.99
|
| Rate for Payer: Nomi Health Commercial |
$73.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$67.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$78.67
|
|
|
DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$89.40
|
|
|
Service Code
|
NDC 409177510
|
| Hospital Charge Code |
2361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.08 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: Aetna Commercial |
$80.46
|
| Rate for Payer: Aetna Medicare |
$33.08
|
| Rate for Payer: ASR ASR |
$86.72
|
| Rate for Payer: BCBS Complete |
$35.76
|
| Rate for Payer: BCBS Trust/PPO |
$73.71
|
| Rate for Payer: BCN Commercial |
$73.71
|
| Rate for Payer: Cash Price |
$71.52
|
| Rate for Payer: Cofinity Commercial |
$84.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.52
|
| Rate for Payer: Healthscope Commercial |
$86.72
|
| Rate for Payer: Healthscope Whirlpool |
$89.40
|
| Rate for Payer: Mclaren Commercial |
$80.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.99
|
| Rate for Payer: Nomi Health Commercial |
$73.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$67.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$78.33
|
| Rate for Payer: Priority Health Narrow Network |
$62.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$78.67
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$74.97
|
|
|
Service Code
|
NDC 409664802
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.74 |
| Max. Negotiated Rate |
$74.97 |
| Rate for Payer: Aetna Commercial |
$67.47
|
| Rate for Payer: Aetna Medicare |
$27.74
|
| Rate for Payer: ASR ASR |
$72.72
|
| Rate for Payer: BCBS Complete |
$29.99
|
| Rate for Payer: BCBS Trust/PPO |
$61.81
|
| Rate for Payer: BCN Commercial |
$61.81
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cofinity Commercial |
$70.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.97
|
| Rate for Payer: Healthscope Commercial |
$72.72
|
| Rate for Payer: Healthscope Whirlpool |
$74.97
|
| Rate for Payer: Mclaren Commercial |
$67.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$59.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: Nomi Health Commercial |
$61.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$65.68
|
| Rate for Payer: Priority Health Narrow Network |
$52.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.97
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$74.97
|
|
|
Service Code
|
NDC 409664802
|
| Hospital Charge Code |
2365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.22 |
| Max. Negotiated Rate |
$74.97 |
| Rate for Payer: Aetna Commercial |
$67.47
|
| Rate for Payer: ASR ASR |
$72.72
|
| Rate for Payer: BCBS Trust/PPO |
$61.56
|
| Rate for Payer: BCN Commercial |
$61.56
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cofinity Commercial |
$70.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.97
|
| Rate for Payer: Healthscope Commercial |
$72.72
|
| Rate for Payer: Healthscope Whirlpool |
$74.97
|
| Rate for Payer: Mclaren Commercial |
$67.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: Nomi Health Commercial |
$61.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.97
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION WRAPPER
|
Facility
|
IP
|
$130.52
|
|
|
Service Code
|
NDC 409751716
|
| Hospital Charge Code |
301983
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.89 |
| Max. Negotiated Rate |
$130.51 |
| Rate for Payer: Aetna Commercial |
$117.46
|
| Rate for Payer: ASR ASR |
$126.60
|
| Rate for Payer: BCBS Trust/PPO |
$107.18
|
| Rate for Payer: BCN Commercial |
$107.18
|
| Rate for Payer: Cash Price |
$104.41
|
| Rate for Payer: Cofinity Commercial |
$122.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.41
|
| Rate for Payer: Healthscope Commercial |
$126.60
|
| Rate for Payer: Healthscope Whirlpool |
$130.51
|
| Rate for Payer: Mclaren Commercial |
$117.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.94
|
| Rate for Payer: Nomi Health Commercial |
$107.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$97.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$114.85
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION WRAPPER
|
Facility
|
IP
|
$130.52
|
|
|
Service Code
|
NDC 409751766
|
| Hospital Charge Code |
301983
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.89 |
| Max. Negotiated Rate |
$130.51 |
| Rate for Payer: Aetna Commercial |
$117.46
|
| Rate for Payer: ASR ASR |
$126.60
|
| Rate for Payer: BCBS Trust/PPO |
$107.18
|
| Rate for Payer: BCN Commercial |
$107.18
|
| Rate for Payer: Cash Price |
$104.41
|
| Rate for Payer: Cofinity Commercial |
$122.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.41
|
| Rate for Payer: Healthscope Commercial |
$126.60
|
| Rate for Payer: Healthscope Whirlpool |
$130.51
|
| Rate for Payer: Mclaren Commercial |
$117.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.94
|
| Rate for Payer: Nomi Health Commercial |
$107.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$97.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$114.85
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION WRAPPER
|
Facility
|
OP
|
$130.52
|
|
|
Service Code
|
NDC 409751766
|
| Hospital Charge Code |
301983
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.29 |
| Max. Negotiated Rate |
$130.51 |
| Rate for Payer: Aetna Commercial |
$117.46
|
| Rate for Payer: Aetna Medicare |
$48.29
|
| Rate for Payer: ASR ASR |
$126.60
|
| Rate for Payer: BCBS Complete |
$52.21
|
| Rate for Payer: BCBS Trust/PPO |
$107.61
|
| Rate for Payer: BCN Commercial |
$107.61
|
| Rate for Payer: Cash Price |
$104.41
|
| Rate for Payer: Cofinity Commercial |
$122.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.41
|
| Rate for Payer: Healthscope Commercial |
$126.60
|
| Rate for Payer: Healthscope Whirlpool |
$130.51
|
| Rate for Payer: Mclaren Commercial |
$117.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.94
|
| Rate for Payer: Nomi Health Commercial |
$107.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$97.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$114.36
|
| Rate for Payer: Priority Health Narrow Network |
$91.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$114.85
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION WRAPPER
|
Facility
|
OP
|
$130.52
|
|
|
Service Code
|
NDC 409751716
|
| Hospital Charge Code |
301983
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.29 |
| Max. Negotiated Rate |
$130.51 |
| Rate for Payer: Aetna Commercial |
$117.46
|
| Rate for Payer: Aetna Medicare |
$48.29
|
| Rate for Payer: ASR ASR |
$126.60
|
| Rate for Payer: BCBS Complete |
$52.21
|
| Rate for Payer: BCBS Trust/PPO |
$107.61
|
| Rate for Payer: BCN Commercial |
$107.61
|
| Rate for Payer: Cash Price |
$104.41
|
| Rate for Payer: Cofinity Commercial |
$122.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.41
|
| Rate for Payer: Healthscope Commercial |
$126.60
|
| Rate for Payer: Healthscope Whirlpool |
$130.51
|
| Rate for Payer: Mclaren Commercial |
$117.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.94
|
| Rate for Payer: Nomi Health Commercial |
$107.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$97.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$114.36
|
| Rate for Payer: Priority Health Narrow Network |
$91.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$114.85
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$65.20
|
|
|
Service Code
|
NDC 409490234
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.90 |
| Max. Negotiated Rate |
$65.20 |
| Rate for Payer: Aetna Commercial |
$58.68
|
| Rate for Payer: ASR ASR |
$63.24
|
| Rate for Payer: BCBS Trust/PPO |
$53.54
|
| Rate for Payer: BCN Commercial |
$53.54
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: Cofinity Commercial |
$61.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.16
|
| Rate for Payer: Healthscope Commercial |
$63.24
|
| Rate for Payer: Healthscope Whirlpool |
$65.20
|
| Rate for Payer: Mclaren Commercial |
$58.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.42
|
| Rate for Payer: Nomi Health Commercial |
$53.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$48.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.38
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
NDC 76329330101
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.25 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$38.70
|
| Rate for Payer: ASR ASR |
$41.71
|
| Rate for Payer: BCBS Trust/PPO |
$35.31
|
| Rate for Payer: BCN Commercial |
$35.31
|
| Rate for Payer: Cash Price |
$34.40
|
| Rate for Payer: Cofinity Commercial |
$40.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.40
|
| Rate for Payer: Healthscope Commercial |
$41.71
|
| Rate for Payer: Healthscope Whirlpool |
$43.00
|
| Rate for Payer: Mclaren Commercial |
$38.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.55
|
| Rate for Payer: Nomi Health Commercial |
$35.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.84
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
NDC 409751716
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$77.00 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Aetna Medicare |
$28.49
|
| Rate for Payer: ASR ASR |
$74.69
|
| Rate for Payer: BCBS Complete |
$30.80
|
| Rate for Payer: BCBS Trust/PPO |
$63.49
|
| Rate for Payer: BCN Commercial |
$63.49
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Cofinity Commercial |
$72.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.60
|
| Rate for Payer: Healthscope Commercial |
$74.69
|
| Rate for Payer: Healthscope Whirlpool |
$77.00
|
| Rate for Payer: Mclaren Commercial |
$69.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.45
|
| Rate for Payer: Nomi Health Commercial |
$63.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$67.47
|
| Rate for Payer: Priority Health Narrow Network |
$53.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$67.76
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
NDC 409751716
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.75 |
| Max. Negotiated Rate |
$77.00 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: ASR ASR |
$74.69
|
| Rate for Payer: BCBS Trust/PPO |
$63.23
|
| Rate for Payer: BCN Commercial |
$63.23
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: Cofinity Commercial |
$72.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.60
|
| Rate for Payer: Healthscope Commercial |
$74.69
|
| Rate for Payer: Healthscope Whirlpool |
$77.00
|
| Rate for Payer: Mclaren Commercial |
$69.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.45
|
| Rate for Payer: Nomi Health Commercial |
$63.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$67.76
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$65.20
|
|
|
Service Code
|
NDC 409490234
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$65.20 |
| Rate for Payer: Aetna Commercial |
$58.68
|
| Rate for Payer: Aetna Medicare |
$24.12
|
| Rate for Payer: ASR ASR |
$63.24
|
| Rate for Payer: BCBS Complete |
$26.08
|
| Rate for Payer: BCBS Trust/PPO |
$53.76
|
| Rate for Payer: BCN Commercial |
$53.76
|
| Rate for Payer: Cash Price |
$52.16
|
| Rate for Payer: Cofinity Commercial |
$61.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.16
|
| Rate for Payer: Healthscope Commercial |
$63.24
|
| Rate for Payer: Healthscope Whirlpool |
$65.20
|
| Rate for Payer: Mclaren Commercial |
$58.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$52.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.42
|
| Rate for Payer: Nomi Health Commercial |
$53.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$48.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$57.13
|
| Rate for Payer: Priority Health Narrow Network |
$45.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.38
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
NDC 76329330101
|
| Hospital Charge Code |
112012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$38.70
|
| Rate for Payer: Aetna Medicare |
$15.91
|
| Rate for Payer: ASR ASR |
$41.71
|
| Rate for Payer: BCBS Complete |
$17.20
|
| Rate for Payer: BCBS Trust/PPO |
$35.45
|
| Rate for Payer: BCN Commercial |
$35.45
|
| Rate for Payer: Cash Price |
$34.40
|
| Rate for Payer: Cofinity Commercial |
$40.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.40
|
| Rate for Payer: Healthscope Commercial |
$41.71
|
| Rate for Payer: Healthscope Whirlpool |
$43.00
|
| Rate for Payer: Mclaren Commercial |
$38.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.55
|
| Rate for Payer: Nomi Health Commercial |
$35.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.25
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$37.68
|
| Rate for Payer: Priority Health Narrow Network |
$30.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.84
|
|
|
DEXTROSE 50% IN WATER (D50W) IV SYRINGE (CODE)
|
Facility
|
OP
|
$98.69
|
|
|
Service Code
|
NDC 76329330101
|
| Hospital Charge Code |
163718
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.51 |
| Max. Negotiated Rate |
$98.69 |
| Rate for Payer: Aetna Commercial |
$88.82
|
| Rate for Payer: Aetna Medicare |
$36.51
|
| Rate for Payer: ASR ASR |
$95.72
|
| Rate for Payer: BCBS Complete |
$39.47
|
| Rate for Payer: BCBS Trust/PPO |
$81.37
|
| Rate for Payer: BCN Commercial |
$81.37
|
| Rate for Payer: Cash Price |
$78.95
|
| Rate for Payer: Cofinity Commercial |
$92.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.95
|
| Rate for Payer: Healthscope Commercial |
$95.72
|
| Rate for Payer: Healthscope Whirlpool |
$98.69
|
| Rate for Payer: Mclaren Commercial |
$88.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.88
|
| Rate for Payer: Nomi Health Commercial |
$80.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$86.47
|
| Rate for Payer: Priority Health Narrow Network |
$69.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$86.84
|
|
