|
DEXTROSE 5 % IV BOLUS
|
Facility
|
OP
|
$55.83
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$55.83 |
| Rate for Payer: Aetna Commercial |
$50.24
|
| Rate for Payer: Aetna Commercial |
$60.47
|
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Medicare |
$24.86
|
| Rate for Payer: Aetna Medicare |
$20.66
|
| Rate for Payer: Aetna Medicare |
$26.56
|
| Rate for Payer: ASR ASR |
$69.62
|
| Rate for Payer: ASR ASR |
$54.15
|
| Rate for Payer: ASR ASR |
$65.17
|
| Rate for Payer: BCBS Complete |
$22.33
|
| Rate for Payer: BCBS Complete |
$28.71
|
| Rate for Payer: BCBS Complete |
$26.87
|
| Rate for Payer: BCBS Trust/PPO |
$46.03
|
| Rate for Payer: BCBS Trust/PPO |
$55.39
|
| Rate for Payer: BCBS Trust/PPO |
$59.18
|
| Rate for Payer: BCN Commercial |
$46.03
|
| Rate for Payer: BCN Commercial |
$55.39
|
| Rate for Payer: BCN Commercial |
$59.18
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$44.66
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$57.42
|
| Rate for Payer: Cash Price |
$57.42
|
| Rate for Payer: Cash Price |
$44.66
|
| Rate for Payer: Cofinity Commercial |
$63.15
|
| Rate for Payer: Cofinity Commercial |
$52.48
|
| Rate for Payer: Cofinity Commercial |
$67.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$69.62
|
| Rate for Payer: Healthscope Commercial |
$54.15
|
| Rate for Payer: Healthscope Commercial |
$65.17
|
| Rate for Payer: Healthscope Whirlpool |
$67.19
|
| Rate for Payer: Healthscope Whirlpool |
$55.83
|
| Rate for Payer: Healthscope Whirlpool |
$71.78
|
| Rate for Payer: Mclaren Commercial |
$64.60
|
| Rate for Payer: Mclaren Commercial |
$60.47
|
| Rate for Payer: Mclaren Commercial |
$50.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$53.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.45
|
| Rate for Payer: Nomi Health Commercial |
$58.86
|
| Rate for Payer: Nomi Health Commercial |
$45.78
|
| Rate for Payer: Nomi Health Commercial |
$55.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$41.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.81
|
| Rate for Payer: Priority Health Narrow Network |
$1.45
|
| Rate for Payer: Priority Health Narrow Network |
$1.45
|
| Rate for Payer: Priority Health Narrow Network |
$1.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$63.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.13
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.44 |
| 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: 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 |
$3.05
|
| Rate for Payer: Priority Health Narrow Network |
$2.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.53
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| 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 5 % IV BOLUS
|
Facility
|
IP
|
$55.83
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.87 |
| Max. Negotiated Rate |
$55.83 |
| Rate for Payer: Aetna Commercial |
$50.24
|
| Rate for Payer: Aetna Commercial |
$64.60
|
| Rate for Payer: Aetna Commercial |
$60.47
|
| Rate for Payer: ASR ASR |
$69.62
|
| Rate for Payer: ASR ASR |
$54.15
|
| Rate for Payer: ASR ASR |
$65.17
|
| Rate for Payer: BCBS Trust/PPO |
$58.94
|
| Rate for Payer: BCBS Trust/PPO |
$45.84
|
| Rate for Payer: BCBS Trust/PPO |
$55.17
|
| Rate for Payer: BCN Commercial |
$55.17
|
| Rate for Payer: BCN Commercial |
$45.84
|
| Rate for Payer: BCN Commercial |
$58.94
|
| Rate for Payer: Cash Price |
$57.42
|
| Rate for Payer: Cash Price |
$44.66
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$52.48
|
| Rate for Payer: Cofinity Commercial |
$63.15
|
| Rate for Payer: Cofinity Commercial |
$67.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$65.17
|
| Rate for Payer: Healthscope Commercial |
$54.15
|
| Rate for Payer: Healthscope Commercial |
$69.62
|
| Rate for Payer: Healthscope Whirlpool |
$67.19
|
| Rate for Payer: Healthscope Whirlpool |
$71.78
|
| Rate for Payer: Healthscope Whirlpool |
$55.83
|
| Rate for Payer: Mclaren Commercial |
$60.47
|
| Rate for Payer: Mclaren Commercial |
$50.24
|
| Rate for Payer: Mclaren Commercial |
$64.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.45
|
| Rate for Payer: Nomi Health Commercial |
$55.09
|
| Rate for Payer: Nomi Health Commercial |
$45.78
|
| Rate for Payer: Nomi Health Commercial |
$58.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$41.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$63.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.13
|
|
|
DIABETES
|
Facility
|
IP
|
$4,040.80
|
|
|
Service Code
|
APR-DRG 4202
|
| Min. Negotiated Rate |
$3,653.37 |
| Max. Negotiated Rate |
$4,040.80 |
| Rate for Payer: BCBS Complete |
$4,040.80
|
| Rate for Payer: Mclaren Medicaid |
$3,848.39
|
| Rate for Payer: Meridian Medicaid |
$4,040.80
|
| Rate for Payer: PHP Medicaid |
$3,653.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,848.39
|
| Rate for Payer: UHC Medicaid |
$3,848.39
|
| Rate for Payer: UHCCP Medicaid |
$3,848.39
|
|
|
DIABETES
|
Facility
|
IP
|
$5,805.90
|
|
|
Service Code
|
APR-DRG 4203
|
| Min. Negotiated Rate |
$5,249.23 |
| Max. Negotiated Rate |
$5,805.90 |
| Rate for Payer: BCBS Complete |
$5,805.90
|
| Rate for Payer: Mclaren Medicaid |
$5,529.43
|
| Rate for Payer: Meridian Medicaid |
$5,805.90
|
| Rate for Payer: PHP Medicaid |
$5,249.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,529.43
|
| Rate for Payer: UHC Medicaid |
$5,529.43
|
| Rate for Payer: UHCCP Medicaid |
$5,529.43
|
|
|
DIABETES
|
Facility
|
IP
|
$8,938.27
|
|
|
Service Code
|
APR-DRG 4204
|
| Min. Negotiated Rate |
$8,081.27 |
| Max. Negotiated Rate |
$8,938.27 |
| Rate for Payer: BCBS Complete |
$8,938.27
|
| Rate for Payer: Mclaren Medicaid |
$8,512.64
|
| Rate for Payer: Meridian Medicaid |
$8,938.27
|
| Rate for Payer: PHP Medicaid |
$8,081.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,512.64
|
| Rate for Payer: UHC Medicaid |
$8,512.64
|
| Rate for Payer: UHCCP Medicaid |
$8,512.64
|
|
|
DIABETES
|
Facility
|
IP
|
$2,874.61
|
|
|
Service Code
|
APR-DRG 4201
|
| Min. Negotiated Rate |
$2,598.99 |
| Max. Negotiated Rate |
$2,874.61 |
| Rate for Payer: BCBS Complete |
$2,874.61
|
| Rate for Payer: Mclaren Medicaid |
$2,737.72
|
| Rate for Payer: Meridian Medicaid |
$2,874.61
|
| Rate for Payer: PHP Medicaid |
$2,598.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,737.72
|
| Rate for Payer: UHC Medicaid |
$2,737.72
|
| Rate for Payer: UHCCP Medicaid |
$2,737.72
|
|
|
DIABETES WITH CC
|
Facility
|
IP
|
$12,722.73
|
|
|
Service Code
|
MSDRG 638
|
| Min. Negotiated Rate |
$7,797.80 |
| Max. Negotiated Rate |
$12,722.73 |
| Rate for Payer: Aetna Medicare |
$8,208.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,260.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,260.26
|
| Rate for Payer: BCBS MAPPO |
$8,208.21
|
| Rate for Payer: BCN Medicare Advantage |
$8,208.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,208.21
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,208.21
|
| Rate for Payer: Mclaren Medicare |
$8,208.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,618.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,439.44
|
| Rate for Payer: Molina Medicare/Medicaid |
$9,029.03
|
| Rate for Payer: PACE Medicare |
$7,797.80
|
| Rate for Payer: PACE SWMI |
$8,208.21
|
| Rate for Payer: PHP Commercial |
$9,029.03
|
| Rate for Payer: PHP Medicare Advantage |
$8,208.21
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$12,312.71
|
| Rate for Payer: Priority Health Medicare |
$8,208.21
|
| Rate for Payer: Priority Health Narrow Network |
$9,850.17
|
| Rate for Payer: Railroad Medicare Medicare |
$8,208.21
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,208.21
|
| Rate for Payer: UHC Exchange |
$12,722.73
|
| Rate for Payer: UHCCP DNSP |
$8,208.21
|
| Rate for Payer: VA VA |
$8,208.21
|
|
|
DIABETES WITH MCC
|
Facility
|
IP
|
$19,738.53
|
|
|
Service Code
|
MSDRG 637
|
| Min. Negotiated Rate |
$11,495.46 |
| Max. Negotiated Rate |
$19,738.53 |
| Rate for Payer: Aetna Medicare |
$12,100.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,125.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,125.60
|
| Rate for Payer: BCBS MAPPO |
$12,100.48
|
| Rate for Payer: BCN Medicare Advantage |
$12,100.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,100.48
|
| Rate for Payer: Humana Choice PPO Medicare |
$12,100.48
|
| Rate for Payer: Mclaren Medicare |
$12,100.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,705.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,915.55
|
| Rate for Payer: Molina Medicare/Medicaid |
$13,310.53
|
| Rate for Payer: PACE Medicare |
$11,495.46
|
| Rate for Payer: PACE SWMI |
$12,100.48
|
| Rate for Payer: PHP Commercial |
$13,310.53
|
| Rate for Payer: PHP Medicare Advantage |
$12,100.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$19,738.53
|
| Rate for Payer: Priority Health Medicare |
$12,100.48
|
| Rate for Payer: Priority Health Narrow Network |
$15,790.83
|
| Rate for Payer: Railroad Medicare Medicare |
$12,100.48
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12,100.48
|
| Rate for Payer: UHC Exchange |
$18,755.74
|
| Rate for Payer: UHCCP DNSP |
$12,100.48
|
| Rate for Payer: VA VA |
$12,100.48
|
|
|
DIABETES WITHOUT CC/MCC
|
Facility
|
IP
|
$9,653.20
|
|
|
Service Code
|
MSDRG 639
|
| Min. Negotiated Rate |
$5,916.48 |
| Max. Negotiated Rate |
$9,653.20 |
| Rate for Payer: Aetna Medicare |
$6,227.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,784.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,784.84
|
| Rate for Payer: BCBS MAPPO |
$6,227.87
|
| Rate for Payer: BCN Medicare Advantage |
$6,227.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,227.87
|
| Rate for Payer: Humana Choice PPO Medicare |
$6,227.87
|
| Rate for Payer: Mclaren Medicare |
$6,227.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,539.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,162.05
|
| Rate for Payer: Molina Medicare/Medicaid |
$6,850.66
|
| Rate for Payer: PACE Medicare |
$5,916.48
|
| Rate for Payer: PACE SWMI |
$6,227.87
|
| Rate for Payer: PHP Commercial |
$6,850.66
|
| Rate for Payer: PHP Medicare Advantage |
$6,227.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8,534.54
|
| Rate for Payer: Priority Health Medicare |
$6,227.87
|
| Rate for Payer: Priority Health Narrow Network |
$6,827.63
|
| Rate for Payer: Railroad Medicare Medicare |
$6,227.87
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,227.87
|
| Rate for Payer: UHC Exchange |
$9,653.20
|
| Rate for Payer: UHCCP DNSP |
$6,227.87
|
| Rate for Payer: VA VA |
$6,227.87
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION
|
Facility
|
OP
|
$79.20
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
27735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.30 |
| Max. Negotiated Rate |
$79.20 |
| Rate for Payer: Aetna Commercial |
$71.28
|
| Rate for Payer: Aetna Medicare |
$29.30
|
| Rate for Payer: ASR ASR |
$76.82
|
| Rate for Payer: BCBS Complete |
$31.68
|
| Rate for Payer: BCBS Trust/PPO |
$65.30
|
| Rate for Payer: BCN Commercial |
$65.30
|
| Rate for Payer: Cash Price |
$63.36
|
| Rate for Payer: Cofinity Commercial |
$74.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.36
|
| Rate for Payer: Healthscope Commercial |
$76.82
|
| Rate for Payer: Healthscope Whirlpool |
$79.20
|
| Rate for Payer: Mclaren Commercial |
$71.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.32
|
| Rate for Payer: Nomi Health Commercial |
$64.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.40
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$69.40
|
| Rate for Payer: Priority Health Narrow Network |
$55.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$69.70
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION
|
Facility
|
IP
|
$79.20
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
27735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.40 |
| Max. Negotiated Rate |
$79.20 |
| Rate for Payer: Aetna Commercial |
$71.28
|
| Rate for Payer: ASR ASR |
$76.82
|
| Rate for Payer: BCBS Trust/PPO |
$65.04
|
| Rate for Payer: BCN Commercial |
$65.04
|
| Rate for Payer: Cash Price |
$63.36
|
| Rate for Payer: Cofinity Commercial |
$74.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.36
|
| Rate for Payer: Healthscope Commercial |
$76.82
|
| Rate for Payer: Healthscope Whirlpool |
$79.20
|
| Rate for Payer: Mclaren Commercial |
$71.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.32
|
| Rate for Payer: Nomi Health Commercial |
$64.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$69.70
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION
|
Facility
|
IP
|
$63.72
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.79 |
| Max. Negotiated Rate |
$63.72 |
| Rate for Payer: Aetna Commercial |
$57.35
|
| Rate for Payer: ASR ASR |
$61.81
|
| Rate for Payer: BCBS Trust/PPO |
$52.33
|
| Rate for Payer: BCN Commercial |
$52.33
|
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: Cofinity Commercial |
$59.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.98
|
| Rate for Payer: Healthscope Commercial |
$61.81
|
| Rate for Payer: Healthscope Whirlpool |
$63.72
|
| Rate for Payer: Mclaren Commercial |
$57.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.16
|
| Rate for Payer: Nomi Health Commercial |
$52.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.07
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION
|
Facility
|
OP
|
$63.72
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.58 |
| Max. Negotiated Rate |
$63.72 |
| Rate for Payer: Aetna Commercial |
$57.35
|
| Rate for Payer: Aetna Medicare |
$23.58
|
| Rate for Payer: ASR ASR |
$61.81
|
| Rate for Payer: BCBS Complete |
$25.49
|
| Rate for Payer: BCBS Trust/PPO |
$52.54
|
| Rate for Payer: BCN Commercial |
$52.54
|
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: Cofinity Commercial |
$59.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.98
|
| Rate for Payer: Healthscope Commercial |
$61.81
|
| Rate for Payer: Healthscope Whirlpool |
$63.72
|
| Rate for Payer: Mclaren Commercial |
$57.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$50.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.16
|
| Rate for Payer: Nomi Health Commercial |
$52.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$55.83
|
| Rate for Payer: Priority Health Narrow Network |
$44.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.07
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$155.10
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.33 |
| Max. Negotiated Rate |
$155.10 |
| Rate for Payer: Aetna Commercial |
$139.59
|
| Rate for Payer: ASR ASR |
$150.45
|
| Rate for Payer: BCBS Trust/PPO |
$127.37
|
| Rate for Payer: BCN Commercial |
$127.37
|
| Rate for Payer: Cash Price |
$124.08
|
| Rate for Payer: Cofinity Commercial |
$145.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.08
|
| Rate for Payer: Healthscope Commercial |
$150.45
|
| Rate for Payer: Healthscope Whirlpool |
$155.10
|
| Rate for Payer: Mclaren Commercial |
$139.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.84
|
| Rate for Payer: Nomi Health Commercial |
$127.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$136.49
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$155.10
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.39 |
| Max. Negotiated Rate |
$155.10 |
| Rate for Payer: Aetna Commercial |
$139.59
|
| Rate for Payer: Aetna Medicare |
$57.39
|
| Rate for Payer: ASR ASR |
$150.45
|
| Rate for Payer: BCBS Complete |
$62.04
|
| Rate for Payer: BCBS Trust/PPO |
$127.88
|
| Rate for Payer: BCN Commercial |
$127.88
|
| Rate for Payer: Cash Price |
$124.08
|
| Rate for Payer: Cofinity Commercial |
$145.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.08
|
| Rate for Payer: Healthscope Commercial |
$150.45
|
| Rate for Payer: Healthscope Whirlpool |
$155.10
|
| Rate for Payer: Mclaren Commercial |
$139.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$124.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.84
|
| Rate for Payer: Nomi Health Commercial |
$127.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$116.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$135.90
|
| Rate for Payer: Priority Health Narrow Network |
$108.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$136.49
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$1.55
|
|
|
Service Code
|
NDC 51079028401
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Aetna Commercial |
$1.40
|
| Rate for Payer: ASR ASR |
$1.50
|
| Rate for Payer: BCBS Trust/PPO |
$1.27
|
| Rate for Payer: BCN Commercial |
$1.27
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cofinity Commercial |
$1.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.24
|
| Rate for Payer: Healthscope Commercial |
$1.50
|
| Rate for Payer: Healthscope Whirlpool |
$1.55
|
| Rate for Payer: Mclaren Commercial |
$1.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.32
|
| Rate for Payer: Nomi Health Commercial |
$1.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.36
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$1.55
|
|
|
Service Code
|
NDC 51079028401
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.55 |
| Rate for Payer: Aetna Commercial |
$1.40
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: ASR ASR |
$1.50
|
| Rate for Payer: BCBS Complete |
$0.62
|
| Rate for Payer: BCBS Trust/PPO |
$1.28
|
| Rate for Payer: BCN Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cofinity Commercial |
$1.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.24
|
| Rate for Payer: Healthscope Commercial |
$1.50
|
| Rate for Payer: Healthscope Whirlpool |
$1.55
|
| Rate for Payer: Mclaren Commercial |
$1.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.32
|
| Rate for Payer: Nomi Health Commercial |
$1.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.16
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.36
|
| Rate for Payer: Priority Health Narrow Network |
$1.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.36
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna Commercial |
$1.31
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: ASR ASR |
$1.41
|
| Rate for Payer: BCBS Complete |
$0.58
|
| Rate for Payer: BCBS Trust/PPO |
$1.20
|
| Rate for Payer: BCN Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cofinity Commercial |
$1.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.17
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Healthscope Whirlpool |
$1.46
|
| Rate for Payer: Mclaren Commercial |
$1.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.24
|
| Rate for Payer: Nomi Health Commercial |
$1.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.28
|
| Rate for Payer: Priority Health Narrow Network |
$1.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.28
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$145.70
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.28 |
| Max. Negotiated Rate |
$145.70 |
| Rate for Payer: Aetna Commercial |
$131.13
|
| Rate for Payer: ASR ASR |
$141.33
|
| Rate for Payer: BCBS Trust/PPO |
$119.65
|
| Rate for Payer: BCN Commercial |
$119.65
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$136.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.56
|
| Rate for Payer: Healthscope Commercial |
$141.33
|
| Rate for Payer: Healthscope Whirlpool |
$145.70
|
| Rate for Payer: Mclaren Commercial |
$131.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.84
|
| Rate for Payer: Nomi Health Commercial |
$119.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$128.22
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna Commercial |
$1.31
|
| Rate for Payer: ASR ASR |
$1.41
|
| Rate for Payer: BCBS Trust/PPO |
$1.20
|
| Rate for Payer: BCN Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cofinity Commercial |
$1.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.17
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Healthscope Whirlpool |
$1.46
|
| Rate for Payer: Mclaren Commercial |
$1.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.24
|
| Rate for Payer: Nomi Health Commercial |
$1.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.28
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$145.70
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.91 |
| Max. Negotiated Rate |
$145.70 |
| Rate for Payer: Aetna Commercial |
$131.13
|
| Rate for Payer: Aetna Medicare |
$53.91
|
| Rate for Payer: ASR ASR |
$141.33
|
| Rate for Payer: BCBS Complete |
$58.28
|
| Rate for Payer: BCBS Trust/PPO |
$120.13
|
| Rate for Payer: BCN Commercial |
$120.13
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$136.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.56
|
| Rate for Payer: Healthscope Commercial |
$141.33
|
| Rate for Payer: Healthscope Whirlpool |
$145.70
|
| Rate for Payer: Mclaren Commercial |
$131.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$116.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.84
|
| Rate for Payer: Nomi Health Commercial |
$119.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$127.66
|
| Rate for Payer: Priority Health Narrow Network |
$102.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$128.22
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
OP
|
$21.66
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.01 |
| Max. Negotiated Rate |
$21.66 |
| Rate for Payer: Aetna Commercial |
$19.49
|
| Rate for Payer: Aetna Medicare |
$8.01
|
| Rate for Payer: ASR ASR |
$21.01
|
| Rate for Payer: BCBS Complete |
$8.66
|
| Rate for Payer: BCBS Trust/PPO |
$17.86
|
| Rate for Payer: BCN Commercial |
$17.86
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$21.01
|
| Rate for Payer: Healthscope Whirlpool |
$21.66
|
| Rate for Payer: Mclaren Commercial |
$19.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.41
|
| Rate for Payer: Nomi Health Commercial |
$17.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18.98
|
| Rate for Payer: Priority Health Narrow Network |
$15.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.06
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$21.66
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.24 |
| Max. Negotiated Rate |
$21.66 |
| Rate for Payer: Aetna Commercial |
$19.49
|
| Rate for Payer: ASR ASR |
$21.01
|
| Rate for Payer: BCBS Trust/PPO |
$17.79
|
| Rate for Payer: BCN Commercial |
$17.79
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$21.01
|
| Rate for Payer: Healthscope Whirlpool |
$21.66
|
| Rate for Payer: Mclaren Commercial |
$19.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.41
|
| Rate for Payer: Nomi Health Commercial |
$17.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.06
|
|
