|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$22.83
|
|
|
Service Code
|
NDC 904535431
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$22.83 |
| Rate for Payer: Aetna Commercial |
$20.55
|
| Rate for Payer: Aetna Medicare |
$8.45
|
| Rate for Payer: ASR ASR |
$22.15
|
| Rate for Payer: BCBS Complete |
$9.13
|
| Rate for Payer: BCBS Trust/PPO |
$18.83
|
| Rate for Payer: BCN Commercial |
$18.83
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cofinity Commercial |
$21.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$22.15
|
| Rate for Payer: Healthscope Whirlpool |
$22.83
|
| Rate for Payer: Mclaren Commercial |
$20.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.41
|
| Rate for Payer: Nomi Health Commercial |
$18.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.13
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$20.01
|
| Rate for Payer: Priority Health Narrow Network |
$16.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.09
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$14.45
|
|
|
Service Code
|
NDC 70000038801
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna Commercial |
$13.00
|
| Rate for Payer: Aetna Medicare |
$5.35
|
| Rate for Payer: ASR ASR |
$14.01
|
| Rate for Payer: BCBS Complete |
$5.78
|
| Rate for Payer: BCBS Trust/PPO |
$11.91
|
| Rate for Payer: BCN Commercial |
$11.91
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$13.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$14.01
|
| Rate for Payer: Healthscope Whirlpool |
$14.45
|
| Rate for Payer: Mclaren Commercial |
$13.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: Nomi Health Commercial |
$11.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$12.66
|
| Rate for Payer: Priority Health Narrow Network |
$10.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.71
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$14.45
|
|
|
Service Code
|
NDC 70000038801
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna Commercial |
$13.00
|
| Rate for Payer: ASR ASR |
$14.01
|
| Rate for Payer: BCBS Trust/PPO |
$11.86
|
| Rate for Payer: BCN Commercial |
$11.86
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$13.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$14.01
|
| Rate for Payer: Healthscope Whirlpool |
$14.45
|
| Rate for Payer: Mclaren Commercial |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: Nomi Health Commercial |
$11.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.71
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.27 |
| Max. Negotiated Rate |
$362.90 |
| Rate for Payer: Aetna Commercial |
$326.61
|
| Rate for Payer: Aetna Medicare |
$134.27
|
| Rate for Payer: ASR ASR |
$352.01
|
| Rate for Payer: BCBS Complete |
$145.16
|
| Rate for Payer: BCBS Trust/PPO |
$299.21
|
| Rate for Payer: BCN Commercial |
$299.21
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$341.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$352.01
|
| Rate for Payer: Healthscope Whirlpool |
$362.90
|
| Rate for Payer: Mclaren Commercial |
$326.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$290.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$272.18
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$317.97
|
| Rate for Payer: Priority Health Narrow Network |
$254.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$319.35
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$301.15
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.86 |
| Max. Negotiated Rate |
$301.15 |
| Rate for Payer: Aetna Commercial |
$271.04
|
| Rate for Payer: ASR ASR |
$292.12
|
| Rate for Payer: BCBS Trust/PPO |
$247.30
|
| Rate for Payer: BCN Commercial |
$247.30
|
| Rate for Payer: Cash Price |
$240.92
|
| Rate for Payer: Cofinity Commercial |
$283.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.92
|
| Rate for Payer: Healthscope Commercial |
$292.12
|
| Rate for Payer: Healthscope Whirlpool |
$301.15
|
| Rate for Payer: Mclaren Commercial |
$271.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.98
|
| Rate for Payer: Nomi Health Commercial |
$246.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$225.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$265.01
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.62 |
| Max. Negotiated Rate |
$312.48 |
| Rate for Payer: Aetna Commercial |
$281.23
|
| Rate for Payer: Aetna Medicare |
$115.62
|
| Rate for Payer: ASR ASR |
$303.11
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: BCBS Trust/PPO |
$257.64
|
| Rate for Payer: BCN Commercial |
$257.64
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$293.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$303.11
|
| Rate for Payer: Healthscope Whirlpool |
$312.48
|
| Rate for Payer: Mclaren Commercial |
$281.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$249.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$273.79
|
| Rate for Payer: Priority Health Narrow Network |
$219.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$274.98
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$272.18 |
| Max. Negotiated Rate |
$362.90 |
| Rate for Payer: Aetna Commercial |
$326.61
|
| Rate for Payer: ASR ASR |
$352.01
|
| Rate for Payer: BCBS Trust/PPO |
$298.01
|
| Rate for Payer: BCN Commercial |
$298.01
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$341.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$352.01
|
| Rate for Payer: Healthscope Whirlpool |
$362.90
|
| Rate for Payer: Mclaren Commercial |
$326.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$272.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$319.35
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$312.48
|
|
|
Service Code
|
NDC 378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.36 |
| Max. Negotiated Rate |
$312.48 |
| Rate for Payer: Aetna Commercial |
$281.23
|
| Rate for Payer: ASR ASR |
$303.11
|
| Rate for Payer: BCBS Trust/PPO |
$256.61
|
| Rate for Payer: BCN Commercial |
$256.61
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$293.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$303.11
|
| Rate for Payer: Healthscope Whirlpool |
$312.48
|
| Rate for Payer: Mclaren Commercial |
$281.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$274.98
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$301.15
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.43 |
| Max. Negotiated Rate |
$301.15 |
| Rate for Payer: Aetna Commercial |
$271.04
|
| Rate for Payer: Aetna Medicare |
$111.43
|
| Rate for Payer: ASR ASR |
$292.12
|
| Rate for Payer: BCBS Complete |
$120.46
|
| Rate for Payer: BCBS Trust/PPO |
$248.30
|
| Rate for Payer: BCN Commercial |
$248.30
|
| Rate for Payer: Cash Price |
$240.92
|
| Rate for Payer: Cofinity Commercial |
$283.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.92
|
| Rate for Payer: Healthscope Commercial |
$292.12
|
| Rate for Payer: Healthscope Whirlpool |
$301.15
|
| Rate for Payer: Mclaren Commercial |
$271.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$240.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.98
|
| Rate for Payer: Nomi Health Commercial |
$246.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$225.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$263.87
|
| Rate for Payer: Priority Health Narrow Network |
$211.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$265.01
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$94.87
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
118045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.15 |
| Max. Negotiated Rate |
$94.87 |
| Rate for Payer: Aetna Commercial |
$85.38
|
| Rate for Payer: ASR ASR |
$92.02
|
| Rate for Payer: BCBS Trust/PPO |
$77.91
|
| Rate for Payer: BCN Commercial |
$77.91
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cofinity Commercial |
$89.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.90
|
| Rate for Payer: Healthscope Commercial |
$92.02
|
| Rate for Payer: Healthscope Whirlpool |
$94.87
|
| Rate for Payer: Mclaren Commercial |
$85.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.64
|
| Rate for Payer: Nomi Health Commercial |
$77.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.49
|
|
|
DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$94.87
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
118045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$94.87 |
| Rate for Payer: Aetna Commercial |
$85.38
|
| Rate for Payer: Aetna Medicare |
$35.10
|
| Rate for Payer: ASR ASR |
$92.02
|
| Rate for Payer: BCBS Complete |
$37.95
|
| Rate for Payer: BCBS Trust/PPO |
$78.22
|
| Rate for Payer: BCN Commercial |
$78.22
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cofinity Commercial |
$89.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.90
|
| Rate for Payer: Healthscope Commercial |
$92.02
|
| Rate for Payer: Healthscope Whirlpool |
$94.87
|
| Rate for Payer: Mclaren Commercial |
$85.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$75.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.64
|
| Rate for Payer: Nomi Health Commercial |
$77.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$33.31
|
| Rate for Payer: Priority Health Narrow Network |
$26.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.49
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$170.37
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.12 |
| Max. Negotiated Rate |
$170.37 |
| Rate for Payer: Aetna Commercial |
$153.33
|
| Rate for Payer: Aetna Medicare |
$63.04
|
| Rate for Payer: ASR ASR |
$165.26
|
| Rate for Payer: BCBS Complete |
$68.15
|
| Rate for Payer: BCBS Trust/PPO |
$140.47
|
| Rate for Payer: BCN Commercial |
$140.47
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Commercial |
$160.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.30
|
| Rate for Payer: Healthscope Commercial |
$165.26
|
| Rate for Payer: Healthscope Whirlpool |
$170.37
|
| Rate for Payer: Mclaren Commercial |
$153.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$136.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Nomi Health Commercial |
$139.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$55.15
|
| Rate for Payer: Priority Health Narrow Network |
$44.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$149.92
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$170.37
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.78 |
| Max. Negotiated Rate |
$170.37 |
| Rate for Payer: Aetna Commercial |
$153.33
|
| Rate for Payer: ASR ASR |
$165.26
|
| Rate for Payer: BCBS Trust/PPO |
$139.91
|
| Rate for Payer: BCN Commercial |
$139.91
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Commercial |
$160.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.30
|
| Rate for Payer: Healthscope Commercial |
$165.26
|
| Rate for Payer: Healthscope Whirlpool |
$170.37
|
| Rate for Payer: Mclaren Commercial |
$153.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Nomi Health Commercial |
$139.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$149.92
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
OP
|
$170.36
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.12 |
| Max. Negotiated Rate |
$170.36 |
| Rate for Payer: Aetna Commercial |
$153.33
|
| Rate for Payer: Aetna Medicare |
$63.03
|
| Rate for Payer: ASR ASR |
$165.25
|
| Rate for Payer: BCBS Complete |
$68.15
|
| Rate for Payer: BCBS Trust/PPO |
$140.47
|
| Rate for Payer: BCN Commercial |
$140.47
|
| Rate for Payer: Cash Price |
$136.29
|
| Rate for Payer: Cash Price |
$136.29
|
| Rate for Payer: Cofinity Commercial |
$160.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.29
|
| Rate for Payer: Healthscope Commercial |
$165.25
|
| Rate for Payer: Healthscope Whirlpool |
$170.36
|
| Rate for Payer: Mclaren Commercial |
$153.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$136.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Nomi Health Commercial |
$139.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$55.15
|
| Rate for Payer: Priority Health Narrow Network |
$44.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$149.92
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
IP
|
$170.36
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.77 |
| Max. Negotiated Rate |
$170.36 |
| Rate for Payer: Aetna Commercial |
$153.33
|
| Rate for Payer: ASR ASR |
$165.25
|
| Rate for Payer: BCBS Trust/PPO |
$139.90
|
| Rate for Payer: BCN Commercial |
$139.90
|
| Rate for Payer: Cash Price |
$136.29
|
| Rate for Payer: Cofinity Commercial |
$160.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.29
|
| Rate for Payer: Healthscope Commercial |
$165.25
|
| Rate for Payer: Healthscope Whirlpool |
$170.36
|
| Rate for Payer: Mclaren Commercial |
$153.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Nomi Health Commercial |
$139.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$149.92
|
|
|
DIPHTH,PERTUSSIS(ACELL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$196.04
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
166805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$147.03 |
| Max. Negotiated Rate |
$196.04 |
| Rate for Payer: Aetna Commercial |
$176.44
|
| Rate for Payer: ASR ASR |
$190.16
|
| Rate for Payer: BCBS Trust/PPO |
$160.99
|
| Rate for Payer: BCN Commercial |
$160.99
|
| Rate for Payer: Cash Price |
$156.83
|
| Rate for Payer: Cofinity Commercial |
$184.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.83
|
| Rate for Payer: Healthscope Commercial |
$190.16
|
| Rate for Payer: Healthscope Whirlpool |
$196.04
|
| Rate for Payer: Mclaren Commercial |
$176.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.63
|
| Rate for Payer: Nomi Health Commercial |
$160.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$147.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.52
|
|
|
DIPHTH,PERTUSSIS(ACELL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$196.04
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
166805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.12 |
| Max. Negotiated Rate |
$196.04 |
| Rate for Payer: Aetna Commercial |
$176.44
|
| Rate for Payer: Aetna Medicare |
$72.54
|
| Rate for Payer: ASR ASR |
$190.16
|
| Rate for Payer: BCBS Complete |
$78.42
|
| Rate for Payer: BCBS Trust/PPO |
$161.64
|
| Rate for Payer: BCN Commercial |
$161.64
|
| Rate for Payer: Cash Price |
$156.83
|
| Rate for Payer: Cash Price |
$156.83
|
| Rate for Payer: Cofinity Commercial |
$184.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.83
|
| Rate for Payer: Healthscope Commercial |
$190.16
|
| Rate for Payer: Healthscope Whirlpool |
$196.04
|
| Rate for Payer: Mclaren Commercial |
$176.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.63
|
| Rate for Payer: Nomi Health Commercial |
$160.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$147.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$55.15
|
| Rate for Payer: Priority Health Narrow Network |
$44.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.52
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$3,494.76
|
|
|
Service Code
|
APR-DRG 2841
|
| Min. Negotiated Rate |
$3,159.69 |
| Max. Negotiated Rate |
$3,494.76 |
| Rate for Payer: BCBS Complete |
$3,494.76
|
| Rate for Payer: Mclaren Medicaid |
$3,328.35
|
| Rate for Payer: Meridian Medicaid |
$3,494.76
|
| Rate for Payer: PHP Medicaid |
$3,159.69
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,328.35
|
| Rate for Payer: UHC Medicaid |
$3,328.35
|
| Rate for Payer: UHCCP Medicaid |
$3,328.35
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$5,362.85
|
|
|
Service Code
|
APR-DRG 2842
|
| Min. Negotiated Rate |
$4,848.66 |
| Max. Negotiated Rate |
$5,362.85 |
| Rate for Payer: BCBS Complete |
$5,362.85
|
| Rate for Payer: Mclaren Medicaid |
$5,107.48
|
| Rate for Payer: Meridian Medicaid |
$5,362.85
|
| Rate for Payer: PHP Medicaid |
$4,848.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,107.48
|
| Rate for Payer: UHC Medicaid |
$5,107.48
|
| Rate for Payer: UHCCP Medicaid |
$5,107.48
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$8,995.49
|
|
|
Service Code
|
APR-DRG 2844
|
| Min. Negotiated Rate |
$8,133.00 |
| Max. Negotiated Rate |
$8,995.49 |
| Rate for Payer: BCBS Complete |
$8,995.49
|
| Rate for Payer: Mclaren Medicaid |
$8,567.13
|
| Rate for Payer: Meridian Medicaid |
$8,995.49
|
| Rate for Payer: PHP Medicaid |
$8,133.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,567.13
|
| Rate for Payer: UHC Medicaid |
$8,567.13
|
| Rate for Payer: UHCCP Medicaid |
$8,567.13
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$6,825.50
|
|
|
Service Code
|
APR-DRG 2843
|
| Min. Negotiated Rate |
$6,171.07 |
| Max. Negotiated Rate |
$6,825.50 |
| Rate for Payer: BCBS Complete |
$6,825.50
|
| Rate for Payer: Mclaren Medicaid |
$6,500.48
|
| Rate for Payer: Meridian Medicaid |
$6,825.50
|
| Rate for Payer: PHP Medicaid |
$6,171.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,500.48
|
| Rate for Payer: UHC Medicaid |
$6,500.48
|
| Rate for Payer: UHCCP Medicaid |
$6,500.48
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC
|
Facility
|
IP
|
$13,494.02
|
|
|
Service Code
|
MSDRG 442
|
| Min. Negotiated Rate |
$8,270.53 |
| Max. Negotiated Rate |
$13,494.02 |
| Rate for Payer: Aetna Medicare |
$8,705.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,882.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,882.27
|
| Rate for Payer: BCBS MAPPO |
$8,705.82
|
| Rate for Payer: BCN Medicare Advantage |
$8,705.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,705.82
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,705.82
|
| Rate for Payer: Mclaren Medicare |
$8,705.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9,141.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,011.69
|
| Rate for Payer: Molina Medicare/Medicaid |
$9,576.40
|
| Rate for Payer: PACE Medicare |
$8,270.53
|
| Rate for Payer: PACE SWMI |
$8,705.82
|
| Rate for Payer: PHP Commercial |
$9,576.40
|
| Rate for Payer: PHP Medicare Advantage |
$8,705.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$13,262.06
|
| Rate for Payer: Priority Health Medicare |
$8,705.82
|
| Rate for Payer: Priority Health Narrow Network |
$10,609.65
|
| Rate for Payer: Railroad Medicare Medicare |
$8,705.82
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,705.82
|
| Rate for Payer: UHC Exchange |
$13,494.02
|
| Rate for Payer: UHCCP DNSP |
$8,705.82
|
| Rate for Payer: VA VA |
$8,705.82
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC
|
Facility
|
IP
|
$24,657.02
|
|
|
Service Code
|
MSDRG 441
|
| Min. Negotiated Rate |
$13,944.60 |
| Max. Negotiated Rate |
$24,657.02 |
| Rate for Payer: Aetna Medicare |
$14,678.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,348.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,348.16
|
| Rate for Payer: BCBS MAPPO |
$14,678.53
|
| Rate for Payer: BCN Medicare Advantage |
$14,678.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,678.53
|
| Rate for Payer: Humana Choice PPO Medicare |
$14,678.53
|
| Rate for Payer: Mclaren Medicare |
$14,678.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15,412.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,880.31
|
| Rate for Payer: Molina Medicare/Medicaid |
$16,146.38
|
| Rate for Payer: PACE Medicare |
$13,944.60
|
| Rate for Payer: PACE SWMI |
$14,678.53
|
| Rate for Payer: PHP Commercial |
$16,146.38
|
| Rate for Payer: PHP Medicare Advantage |
$14,678.53
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$24,657.02
|
| Rate for Payer: Priority Health Medicare |
$14,678.53
|
| Rate for Payer: Priority Health Narrow Network |
$19,725.62
|
| Rate for Payer: Railroad Medicare Medicare |
$14,678.53
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$14,678.53
|
| Rate for Payer: UHC Exchange |
$22,751.72
|
| Rate for Payer: UHCCP DNSP |
$14,678.53
|
| Rate for Payer: VA VA |
$14,678.53
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$10,529.41
|
|
|
Service Code
|
MSDRG 443
|
| Min. Negotiated Rate |
$6,453.51 |
| Max. Negotiated Rate |
$10,529.41 |
| Rate for Payer: Aetna Medicare |
$6,793.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,491.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,491.46
|
| Rate for Payer: BCBS MAPPO |
$6,793.17
|
| Rate for Payer: BCN Medicare Advantage |
$6,793.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,793.17
|
| Rate for Payer: Humana Choice PPO Medicare |
$6,793.17
|
| Rate for Payer: Mclaren Medicare |
$6,793.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,132.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,812.15
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,472.49
|
| Rate for Payer: PACE Medicare |
$6,453.51
|
| Rate for Payer: PACE SWMI |
$6,793.17
|
| Rate for Payer: PHP Commercial |
$7,472.49
|
| Rate for Payer: PHP Medicare Advantage |
$6,793.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$9,613.04
|
| Rate for Payer: Priority Health Medicare |
$6,793.17
|
| Rate for Payer: Priority Health Narrow Network |
$7,690.43
|
| Rate for Payer: Railroad Medicare Medicare |
$6,793.17
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,793.17
|
| Rate for Payer: UHC Exchange |
$10,529.41
|
| Rate for Payer: UHCCP DNSP |
$6,793.17
|
| Rate for Payer: VA VA |
$6,793.17
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY
|
Facility
|
IP
|
$6,355.75
|
|
|
Service Code
|
APR-DRG 2823
|
| Min. Negotiated Rate |
$5,746.36 |
| Max. Negotiated Rate |
$6,355.75 |
| Rate for Payer: BCBS Complete |
$6,355.75
|
| Rate for Payer: Mclaren Medicaid |
$6,053.10
|
| Rate for Payer: Meridian Medicaid |
$6,355.75
|
| Rate for Payer: PHP Medicaid |
$5,746.36
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,053.10
|
| Rate for Payer: UHC Medicaid |
$6,053.10
|
| Rate for Payer: UHCCP Medicaid |
$6,053.10
|
|
