|
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC
|
Facility
IP
|
$25,456.58
|
|
|
Service Code
|
MS-DRG 871
|
| Min. Negotiated Rate |
$17,543.11 |
| Max. Negotiated Rate |
$25,456.58 |
| Rate for Payer: Aetna Medicare |
$18,466.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23,083.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23,083.04
|
| Rate for Payer: BCBS MAPPO |
$18,466.43
|
| Rate for Payer: BCN Medicare Advantage |
$18,466.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18,466.43
|
| Rate for Payer: Humana Choice PPO Medicare |
$18,466.43
|
| Rate for Payer: Mclaren Medicare |
$18,466.43
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19,389.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21,236.39
|
| Rate for Payer: PACE Medicare |
$17,543.11
|
| Rate for Payer: PACE SWMI |
$18,466.43
|
| Rate for Payer: PHP Commercial |
$20,313.07
|
| Rate for Payer: PHP Medicare Advantage |
$18,466.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25,456.58
|
| Rate for Payer: Priority Health Medicare |
$18,466.43
|
| Rate for Payer: Priority Health Narrow Network |
$20,365.26
|
| Rate for Payer: Railroad Medicare Medicare |
$18,466.43
|
| Rate for Payer: UHC Medicare Advantage |
$19,020.42
|
| Rate for Payer: VA VA |
$18,466.43
|
|
|
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC
|
Facility
IP
|
$13,223.92
|
|
|
Service Code
|
MS-DRG 872
|
| Min. Negotiated Rate |
$9,880.47 |
| Max. Negotiated Rate |
$13,223.92 |
| Rate for Payer: Aetna Medicare |
$10,400.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,000.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,000.61
|
| Rate for Payer: BCBS MAPPO |
$10,400.49
|
| Rate for Payer: BCN Medicare Advantage |
$10,400.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,400.49
|
| Rate for Payer: Humana Choice PPO Medicare |
$10,400.49
|
| Rate for Payer: Mclaren Medicare |
$10,400.49
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,920.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,960.56
|
| Rate for Payer: PACE Medicare |
$9,880.47
|
| Rate for Payer: PACE SWMI |
$10,400.49
|
| Rate for Payer: PHP Commercial |
$11,440.54
|
| Rate for Payer: PHP Medicare Advantage |
$10,400.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,223.92
|
| Rate for Payer: Priority Health Medicare |
$10,400.49
|
| Rate for Payer: Priority Health Narrow Network |
$10,579.14
|
| Rate for Payer: Railroad Medicare Medicare |
$10,400.49
|
| Rate for Payer: UHC Medicare Advantage |
$10,712.50
|
| Rate for Payer: VA VA |
$10,400.49
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$286.90
|
|
|
Service Code
|
NDC 60687-242-01
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.83 |
| Max. Negotiated Rate |
$286.90 |
| Rate for Payer: Aetna Commercial |
$258.21
|
| Rate for Payer: ASR ASR |
$278.29
|
| Rate for Payer: BCBS Trust/PPO |
$222.43
|
| Rate for Payer: BCN Commercial |
$222.43
|
| Rate for Payer: Cash Price |
$229.52
|
| Rate for Payer: Cofinity Commercial |
$269.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.52
|
| Rate for Payer: Healthscope Commercial |
$286.90
|
| Rate for Payer: Healthscope Whirlpool |
$278.29
|
| Rate for Payer: Mclaren Commercial |
$258.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$243.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$252.47
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$4,739.70
|
|
|
Service Code
|
NDC 0049-4900-41
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,317.79 |
| Max. Negotiated Rate |
$4,739.70 |
| Rate for Payer: Aetna Commercial |
$4,265.73
|
| Rate for Payer: ASR ASR |
$4,597.51
|
| Rate for Payer: BCBS Trust/PPO |
$3,674.69
|
| Rate for Payer: BCN Commercial |
$3,674.69
|
| Rate for Payer: Cash Price |
$3,791.76
|
| Rate for Payer: Cofinity Commercial |
$4,455.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,791.76
|
| Rate for Payer: Healthscope Commercial |
$4,739.70
|
| Rate for Payer: Healthscope Whirlpool |
$4,597.51
|
| Rate for Payer: Mclaren Commercial |
$4,265.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,028.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,317.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,170.94
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$271.70
|
|
|
Service Code
|
NDC 0904-6925-61
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.19 |
| Max. Negotiated Rate |
$271.70 |
| Rate for Payer: Aetna Commercial |
$244.53
|
| Rate for Payer: ASR ASR |
$263.55
|
| Rate for Payer: BCBS Trust/PPO |
$210.65
|
| Rate for Payer: BCN Commercial |
$210.65
|
| Rate for Payer: Cash Price |
$217.36
|
| Rate for Payer: Cofinity Commercial |
$255.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.36
|
| Rate for Payer: Healthscope Commercial |
$271.70
|
| Rate for Payer: Healthscope Whirlpool |
$263.55
|
| Rate for Payer: Mclaren Commercial |
$244.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$230.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$239.10
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$225.60
|
|
|
Service Code
|
NDC 59762-4900-3
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.92 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: BCBS Trust/PPO |
$174.91
|
| Rate for Payer: BCN Commercial |
$174.91
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$225.60
|
| Rate for Payer: Healthscope Whirlpool |
$218.83
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$31.02
|
|
|
Service Code
|
NDC 68180-352-06
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$31.02 |
| Rate for Payer: Aetna Commercial |
$27.92
|
| Rate for Payer: ASR ASR |
$30.09
|
| Rate for Payer: BCBS Trust/PPO |
$24.05
|
| Rate for Payer: BCN Commercial |
$24.05
|
| Rate for Payer: Cash Price |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$29.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.82
|
| Rate for Payer: Healthscope Commercial |
$31.02
|
| Rate for Payer: Healthscope Whirlpool |
$30.09
|
| Rate for Payer: Mclaren Commercial |
$27.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.30
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
IP
|
$2.87
|
|
|
Service Code
|
NDC 60687-242-11
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.58
|
| Rate for Payer: ASR ASR |
$2.78
|
| Rate for Payer: BCBS Trust/PPO |
$2.23
|
| Rate for Payer: BCN Commercial |
$2.23
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cofinity Commercial |
$2.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.30
|
| Rate for Payer: Healthscope Commercial |
$2.87
|
| Rate for Payer: Healthscope Whirlpool |
$2.78
|
| Rate for Payer: Mclaren Commercial |
$2.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.53
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC
|
Facility
IP
|
$25,600.39
|
|
|
Service Code
|
MS-DRG 511
|
| Min. Negotiated Rate |
$17,633.18 |
| Max. Negotiated Rate |
$25,600.39 |
| Rate for Payer: Aetna Medicare |
$18,561.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23,201.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23,201.55
|
| Rate for Payer: BCBS MAPPO |
$18,561.24
|
| Rate for Payer: BCN Medicare Advantage |
$18,561.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18,561.24
|
| Rate for Payer: Humana Choice PPO Medicare |
$18,561.24
|
| Rate for Payer: Mclaren Medicare |
$18,561.24
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19,489.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21,345.43
|
| Rate for Payer: PACE Medicare |
$17,633.18
|
| Rate for Payer: PACE SWMI |
$18,561.24
|
| Rate for Payer: PHP Commercial |
$20,417.36
|
| Rate for Payer: PHP Medicare Advantage |
$18,561.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25,600.39
|
| Rate for Payer: Priority Health Medicare |
$18,561.24
|
| Rate for Payer: Priority Health Narrow Network |
$20,480.31
|
| Rate for Payer: Railroad Medicare Medicare |
$18,561.24
|
| Rate for Payer: UHC Medicare Advantage |
$19,118.08
|
| Rate for Payer: VA VA |
$18,561.24
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC
|
Facility
IP
|
$34,932.50
|
|
|
Service Code
|
MS-DRG 510
|
| Min. Negotiated Rate |
$23,478.88 |
| Max. Negotiated Rate |
$34,932.50 |
| Rate for Payer: Aetna Medicare |
$24,714.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30,893.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30,893.26
|
| Rate for Payer: BCBS MAPPO |
$24,714.61
|
| Rate for Payer: BCN Medicare Advantage |
$24,714.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24,714.61
|
| Rate for Payer: Humana Choice PPO Medicare |
$24,714.61
|
| Rate for Payer: Mclaren Medicare |
$24,714.61
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$25,950.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28,421.80
|
| Rate for Payer: PACE Medicare |
$23,478.88
|
| Rate for Payer: PACE SWMI |
$24,714.61
|
| Rate for Payer: PHP Commercial |
$27,186.07
|
| Rate for Payer: PHP Medicare Advantage |
$24,714.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34,932.50
|
| Rate for Payer: Priority Health Medicare |
$24,714.61
|
| Rate for Payer: Priority Health Narrow Network |
$27,946.00
|
| Rate for Payer: Railroad Medicare Medicare |
$24,714.61
|
| Rate for Payer: UHC Medicare Advantage |
$25,456.05
|
| Rate for Payer: VA VA |
$24,714.61
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC
|
Facility
IP
|
$20,721.19
|
|
|
Service Code
|
MS-DRG 512
|
| Min. Negotiated Rate |
$14,576.81 |
| Max. Negotiated Rate |
$20,721.19 |
| Rate for Payer: Aetna Medicare |
$15,344.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19,180.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19,180.01
|
| Rate for Payer: BCBS MAPPO |
$15,344.01
|
| Rate for Payer: BCN Medicare Advantage |
$15,344.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15,344.01
|
| Rate for Payer: Humana Choice PPO Medicare |
$15,344.01
|
| Rate for Payer: Mclaren Medicare |
$15,344.01
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$16,111.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17,645.61
|
| Rate for Payer: PACE Medicare |
$14,576.81
|
| Rate for Payer: PACE SWMI |
$15,344.01
|
| Rate for Payer: PHP Commercial |
$16,878.41
|
| Rate for Payer: PHP Medicare Advantage |
$15,344.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,721.19
|
| Rate for Payer: Priority Health Medicare |
$15,344.01
|
| Rate for Payer: Priority Health Narrow Network |
$16,576.95
|
| Rate for Payer: Railroad Medicare Medicare |
$15,344.01
|
| Rate for Payer: UHC Medicare Advantage |
$15,804.33
|
| Rate for Payer: VA VA |
$15,344.01
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
IP
|
$17,963.16
|
|
|
Service Code
|
MS-DRG 555
|
| Min. Negotiated Rate |
$12,849.16 |
| Max. Negotiated Rate |
$17,963.16 |
| Rate for Payer: Aetna Medicare |
$13,525.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16,906.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16,906.79
|
| Rate for Payer: BCBS MAPPO |
$13,525.43
|
| Rate for Payer: BCN Medicare Advantage |
$13,525.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,525.43
|
| Rate for Payer: Humana Choice PPO Medicare |
$13,525.43
|
| Rate for Payer: Mclaren Medicare |
$13,525.43
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,201.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,554.24
|
| Rate for Payer: PACE Medicare |
$12,849.16
|
| Rate for Payer: PACE SWMI |
$13,525.43
|
| Rate for Payer: PHP Commercial |
$14,877.97
|
| Rate for Payer: PHP Medicare Advantage |
$13,525.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,963.16
|
| Rate for Payer: Priority Health Medicare |
$13,525.43
|
| Rate for Payer: Priority Health Narrow Network |
$14,370.53
|
| Rate for Payer: Railroad Medicare Medicare |
$13,525.43
|
| Rate for Payer: UHC Medicare Advantage |
$13,931.19
|
| Rate for Payer: VA VA |
$13,525.43
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC
|
Facility
IP
|
$10,825.80
|
|
|
Service Code
|
MS-DRG 556
|
| Min. Negotiated Rate |
$8,227.61 |
| Max. Negotiated Rate |
$10,825.80 |
| Rate for Payer: Aetna Medicare |
$8,660.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,825.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,825.80
|
| Rate for Payer: BCBS MAPPO |
$8,660.64
|
| Rate for Payer: BCN Medicare Advantage |
$8,660.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,660.64
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,660.64
|
| Rate for Payer: Mclaren Medicare |
$8,660.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,093.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,959.74
|
| Rate for Payer: PACE Medicare |
$8,227.61
|
| Rate for Payer: PACE SWMI |
$8,660.64
|
| Rate for Payer: PHP Commercial |
$9,526.70
|
| Rate for Payer: PHP Medicare Advantage |
$8,660.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,585.30
|
| Rate for Payer: Priority Health Medicare |
$8,660.64
|
| Rate for Payer: Priority Health Narrow Network |
$8,468.24
|
| Rate for Payer: Railroad Medicare Medicare |
$8,660.64
|
| Rate for Payer: UHC Medicare Advantage |
$8,920.46
|
| Rate for Payer: VA VA |
$8,660.64
|
|
|
SIGNS AND SYMPTOMS WITH MCC
|
Facility
IP
|
$16,070.54
|
|
|
Service Code
|
MS-DRG 947
|
| Min. Negotiated Rate |
$11,663.61 |
| Max. Negotiated Rate |
$16,070.54 |
| Rate for Payer: Aetna Medicare |
$12,277.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,346.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,346.85
|
| Rate for Payer: BCBS MAPPO |
$12,277.48
|
| Rate for Payer: BCN Medicare Advantage |
$12,277.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,277.48
|
| Rate for Payer: Humana Choice PPO Medicare |
$12,277.48
|
| Rate for Payer: Mclaren Medicare |
$12,277.48
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,891.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,119.10
|
| Rate for Payer: PACE Medicare |
$11,663.61
|
| Rate for Payer: PACE SWMI |
$12,277.48
|
| Rate for Payer: PHP Commercial |
$13,505.23
|
| Rate for Payer: PHP Medicare Advantage |
$12,277.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,070.54
|
| Rate for Payer: Priority Health Medicare |
$12,277.48
|
| Rate for Payer: Priority Health Narrow Network |
$12,856.43
|
| Rate for Payer: Railroad Medicare Medicare |
$12,277.48
|
| Rate for Payer: UHC Medicare Advantage |
$12,645.80
|
| Rate for Payer: VA VA |
$12,277.48
|
|
|
SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
IP
|
$10,578.14
|
|
|
Service Code
|
MS-DRG 948
|
| Min. Negotiated Rate |
$8,039.38 |
| Max. Negotiated Rate |
$10,578.14 |
| Rate for Payer: Aetna Medicare |
$8,462.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,578.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,578.14
|
| Rate for Payer: BCBS MAPPO |
$8,462.51
|
| Rate for Payer: BCN Medicare Advantage |
$8,462.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,462.51
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,462.51
|
| Rate for Payer: Mclaren Medicare |
$8,462.51
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,885.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,731.89
|
| Rate for Payer: PACE Medicare |
$8,039.38
|
| Rate for Payer: PACE SWMI |
$8,462.51
|
| Rate for Payer: PHP Commercial |
$9,308.76
|
| Rate for Payer: PHP Medicare Advantage |
$8,462.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,284.84
|
| Rate for Payer: Priority Health Medicare |
$8,462.51
|
| Rate for Payer: Priority Health Narrow Network |
$8,227.87
|
| Rate for Payer: Railroad Medicare Medicare |
$8,462.51
|
| Rate for Payer: UHC Medicare Advantage |
$8,716.39
|
| Rate for Payer: VA VA |
$8,462.51
|
|
|
SILDENAFIL (REVATIO) 20 MG TABLET
|
Facility
IP
|
$120.27
|
|
|
Service Code
|
NDC 0904-6671-04
|
| Hospital Charge Code |
41832
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.19 |
| Max. Negotiated Rate |
$120.27 |
| Rate for Payer: Aetna Commercial |
$108.24
|
| Rate for Payer: ASR ASR |
$116.66
|
| Rate for Payer: BCBS Trust/PPO |
$93.25
|
| Rate for Payer: BCN Commercial |
$93.25
|
| Rate for Payer: Cash Price |
$96.22
|
| Rate for Payer: Cofinity Commercial |
$113.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.22
|
| Rate for Payer: Healthscope Commercial |
$120.27
|
| Rate for Payer: Healthscope Whirlpool |
$116.66
|
| Rate for Payer: Mclaren Commercial |
$108.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$102.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.84
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
IP
|
$5.16
|
|
|
Service Code
|
NDC 9900-0009-76
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: ASR ASR |
$5.01
|
| Rate for Payer: BCBS Trust/PPO |
$4.00
|
| Rate for Payer: BCN Commercial |
$4.00
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$4.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$5.16
|
| Rate for Payer: Healthscope Whirlpool |
$5.01
|
| Rate for Payer: Mclaren Commercial |
$4.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.54
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
IP
|
$78.05
|
|
|
Service Code
|
NDC 12165-100-03
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.64 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna Commercial |
$70.24
|
| Rate for Payer: ASR ASR |
$75.71
|
| Rate for Payer: BCBS Trust/PPO |
$60.51
|
| Rate for Payer: BCN Commercial |
$60.51
|
| Rate for Payer: Cash Price |
$62.44
|
| Rate for Payer: Cofinity Commercial |
$73.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.44
|
| Rate for Payer: Healthscope Commercial |
$78.05
|
| Rate for Payer: Healthscope Whirlpool |
$75.71
|
| Rate for Payer: Mclaren Commercial |
$70.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.68
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
IP
|
$31.43
|
|
|
Service Code
|
NDC 61570-131-20
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$31.43 |
| Rate for Payer: Aetna Commercial |
$28.29
|
| Rate for Payer: ASR ASR |
$30.49
|
| Rate for Payer: BCBS Trust/PPO |
$24.37
|
| Rate for Payer: BCN Commercial |
$24.37
|
| Rate for Payer: Cash Price |
$25.14
|
| Rate for Payer: Cofinity Commercial |
$29.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.14
|
| Rate for Payer: Healthscope Commercial |
$31.43
|
| Rate for Payer: Healthscope Whirlpool |
$30.49
|
| Rate for Payer: Mclaren Commercial |
$28.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.66
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
IP
|
$12.71
|
|
|
Service Code
|
NDC 67877-124-25
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$12.71 |
| Rate for Payer: Aetna Commercial |
$11.44
|
| Rate for Payer: ASR ASR |
$12.33
|
| Rate for Payer: BCBS Trust/PPO |
$9.85
|
| Rate for Payer: BCN Commercial |
$9.85
|
| Rate for Payer: Cash Price |
$10.17
|
| Rate for Payer: Cofinity Commercial |
$11.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.17
|
| Rate for Payer: Healthscope Commercial |
$12.71
|
| Rate for Payer: Healthscope Whirlpool |
$12.33
|
| Rate for Payer: Mclaren Commercial |
$11.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.18
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
IP
|
$26.32
|
|
|
Service Code
|
NDC 43598-210-25
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.42 |
| Max. Negotiated Rate |
$26.32 |
| Rate for Payer: Aetna Commercial |
$23.69
|
| Rate for Payer: ASR ASR |
$25.53
|
| Rate for Payer: BCBS Trust/PPO |
$20.41
|
| Rate for Payer: BCN Commercial |
$20.41
|
| Rate for Payer: Cash Price |
$21.06
|
| Rate for Payer: Cofinity Commercial |
$24.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.06
|
| Rate for Payer: Healthscope Commercial |
$26.32
|
| Rate for Payer: Healthscope Whirlpool |
$25.53
|
| Rate for Payer: Mclaren Commercial |
$23.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.16
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
IP
|
$10.98
|
|
|
Service Code
|
NDC 0536-2220-75
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$10.98 |
| Rate for Payer: Aetna Commercial |
$9.88
|
| Rate for Payer: ASR ASR |
$10.65
|
| Rate for Payer: BCBS Trust/PPO |
$8.51
|
| Rate for Payer: BCN Commercial |
$8.51
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cofinity Commercial |
$10.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.78
|
| Rate for Payer: Healthscope Commercial |
$10.98
|
| Rate for Payer: Healthscope Whirlpool |
$10.65
|
| Rate for Payer: Mclaren Commercial |
$9.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.66
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
IP
|
$10.26
|
|
|
Service Code
|
NDC 0904-5894-30
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Aetna Commercial |
$9.23
|
| Rate for Payer: ASR ASR |
$9.95
|
| Rate for Payer: BCBS Trust/PPO |
$7.95
|
| Rate for Payer: BCN Commercial |
$7.95
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$10.26
|
| Rate for Payer: Healthscope Whirlpool |
$9.95
|
| Rate for Payer: Mclaren Commercial |
$9.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.03
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
IP
|
$103.40
|
|
|
Service Code
|
NDC 63739-225-10
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.38 |
| Max. Negotiated Rate |
$103.40 |
| Rate for Payer: Aetna Commercial |
$93.06
|
| Rate for Payer: ASR ASR |
$100.30
|
| Rate for Payer: BCBS Trust/PPO |
$80.17
|
| Rate for Payer: BCN Commercial |
$80.17
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Commercial |
$97.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Healthscope Commercial |
$103.40
|
| Rate for Payer: Healthscope Whirlpool |
$100.30
|
| Rate for Payer: Mclaren Commercial |
$93.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$90.99
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
IP
|
$3.41
|
|
|
Service Code
|
NDC 77333-812-25
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$3.41 |
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: ASR ASR |
$3.31
|
| Rate for Payer: BCBS Trust/PPO |
$2.64
|
| Rate for Payer: BCN Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cofinity Commercial |
$3.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.73
|
| Rate for Payer: Healthscope Commercial |
$3.41
|
| Rate for Payer: Healthscope Whirlpool |
$3.31
|
| Rate for Payer: Mclaren Commercial |
$3.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.00
|
|
