|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC
|
Facility
IP
|
$49,120.70
|
|
|
Service Code
|
MS-DRG 622
|
| Min. Negotiated Rate |
$32,366.49 |
| Max. Negotiated Rate |
$49,120.70 |
| Rate for Payer: Aetna Medicare |
$34,069.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$42,587.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$42,587.49
|
| Rate for Payer: BCBS MAPPO |
$34,069.99
|
| Rate for Payer: BCN Medicare Advantage |
$34,069.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34,069.99
|
| Rate for Payer: Humana Choice PPO Medicare |
$34,069.99
|
| Rate for Payer: Mclaren Medicare |
$34,069.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$35,773.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39,180.49
|
| Rate for Payer: PACE Medicare |
$32,366.49
|
| Rate for Payer: PACE SWMI |
$34,069.99
|
| Rate for Payer: PHP Commercial |
$37,476.99
|
| Rate for Payer: PHP Medicare Advantage |
$34,069.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49,120.70
|
| Rate for Payer: Priority Health Medicare |
$34,069.99
|
| Rate for Payer: Priority Health Narrow Network |
$39,296.56
|
| Rate for Payer: Railroad Medicare Medicare |
$34,069.99
|
| Rate for Payer: UHC Medicare Advantage |
$35,092.09
|
| Rate for Payer: VA VA |
$34,069.99
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC
|
Facility
IP
|
$14,310.18
|
|
|
Service Code
|
MS-DRG 624
|
| Min. Negotiated Rate |
$10,560.91 |
| Max. Negotiated Rate |
$14,310.18 |
| Rate for Payer: Aetna Medicare |
$11,116.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,895.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,895.94
|
| Rate for Payer: BCBS MAPPO |
$11,116.75
|
| Rate for Payer: BCN Medicare Advantage |
$11,116.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,116.75
|
| Rate for Payer: Humana Choice PPO Medicare |
$11,116.75
|
| Rate for Payer: Mclaren Medicare |
$11,116.75
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,672.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,784.26
|
| Rate for Payer: PACE Medicare |
$10,560.91
|
| Rate for Payer: PACE SWMI |
$11,116.75
|
| Rate for Payer: PHP Commercial |
$12,228.42
|
| Rate for Payer: PHP Medicare Advantage |
$11,116.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14,310.18
|
| Rate for Payer: Priority Health Medicare |
$11,116.75
|
| Rate for Payer: Priority Health Narrow Network |
$11,448.14
|
| Rate for Payer: Railroad Medicare Medicare |
$11,116.75
|
| Rate for Payer: UHC Medicare Advantage |
$11,450.25
|
| Rate for Payer: VA VA |
$11,116.75
|
|
|
SKIN GRAFTS FOR INJURIES WITH CC/MCC
|
Facility
IP
|
$41,809.61
|
|
|
Service Code
|
MS-DRG 904
|
| Min. Negotiated Rate |
$27,786.77 |
| Max. Negotiated Rate |
$41,809.61 |
| Rate for Payer: Aetna Medicare |
$29,249.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$36,561.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$36,561.54
|
| Rate for Payer: BCBS MAPPO |
$29,249.23
|
| Rate for Payer: BCN Medicare Advantage |
$29,249.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29,249.23
|
| Rate for Payer: Humana Choice PPO Medicare |
$29,249.23
|
| Rate for Payer: Mclaren Medicare |
$29,249.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$30,711.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33,636.61
|
| Rate for Payer: PACE Medicare |
$27,786.77
|
| Rate for Payer: PACE SWMI |
$29,249.23
|
| Rate for Payer: PHP Commercial |
$32,174.15
|
| Rate for Payer: PHP Medicare Advantage |
$29,249.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$41,809.61
|
| Rate for Payer: Priority Health Medicare |
$29,249.23
|
| Rate for Payer: Priority Health Narrow Network |
$33,447.69
|
| Rate for Payer: Railroad Medicare Medicare |
$29,249.23
|
| Rate for Payer: UHC Medicare Advantage |
$30,126.71
|
| Rate for Payer: VA VA |
$29,249.23
|
|
|
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC
|
Facility
IP
|
$20,334.71
|
|
|
Service Code
|
MS-DRG 905
|
| Min. Negotiated Rate |
$14,334.70 |
| Max. Negotiated Rate |
$20,334.71 |
| Rate for Payer: Aetna Medicare |
$15,089.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,861.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,861.45
|
| Rate for Payer: BCBS MAPPO |
$15,089.16
|
| Rate for Payer: BCN Medicare Advantage |
$15,089.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15,089.16
|
| Rate for Payer: Humana Choice PPO Medicare |
$15,089.16
|
| Rate for Payer: Mclaren Medicare |
$15,089.16
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15,843.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17,352.53
|
| Rate for Payer: PACE Medicare |
$14,334.70
|
| Rate for Payer: PACE SWMI |
$15,089.16
|
| Rate for Payer: PHP Commercial |
$16,598.08
|
| Rate for Payer: PHP Medicare Advantage |
$15,089.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,334.71
|
| Rate for Payer: Priority Health Medicare |
$15,089.16
|
| Rate for Payer: Priority Health Narrow Network |
$16,267.77
|
| Rate for Payer: Railroad Medicare Medicare |
$15,089.16
|
| Rate for Payer: UHC Medicare Advantage |
$15,541.83
|
| Rate for Payer: VA VA |
$15,089.16
|
|
|
SKIN ULCERS WITH CC
|
Facility
IP
|
$15,535.12
|
|
|
Service Code
|
MS-DRG 593
|
| Min. Negotiated Rate |
$11,328.22 |
| Max. Negotiated Rate |
$15,535.12 |
| Rate for Payer: Aetna Medicare |
$11,924.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,905.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,905.55
|
| Rate for Payer: BCBS MAPPO |
$11,924.44
|
| Rate for Payer: BCN Medicare Advantage |
$11,924.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,924.44
|
| Rate for Payer: Humana Choice PPO Medicare |
$11,924.44
|
| Rate for Payer: Mclaren Medicare |
$11,924.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,520.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,713.11
|
| Rate for Payer: PACE Medicare |
$11,328.22
|
| Rate for Payer: PACE SWMI |
$11,924.44
|
| Rate for Payer: PHP Commercial |
$13,116.88
|
| Rate for Payer: PHP Medicare Advantage |
$11,924.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,535.12
|
| Rate for Payer: Priority Health Medicare |
$11,924.44
|
| Rate for Payer: Priority Health Narrow Network |
$12,428.10
|
| Rate for Payer: Railroad Medicare Medicare |
$11,924.44
|
| Rate for Payer: UHC Medicare Advantage |
$12,282.17
|
| Rate for Payer: VA VA |
$11,924.44
|
|
|
SKIN ULCERS WITH MCC
|
Facility
IP
|
$26,836.88
|
|
|
Service Code
|
MS-DRG 592
|
| Min. Negotiated Rate |
$18,407.73 |
| Max. Negotiated Rate |
$26,836.88 |
| Rate for Payer: Aetna Medicare |
$19,376.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,220.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,220.70
|
| Rate for Payer: BCBS MAPPO |
$19,376.56
|
| Rate for Payer: BCN Medicare Advantage |
$19,376.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,376.56
|
| Rate for Payer: Humana Choice PPO Medicare |
$19,376.56
|
| Rate for Payer: Mclaren Medicare |
$19,376.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$20,345.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,283.04
|
| Rate for Payer: PACE Medicare |
$18,407.73
|
| Rate for Payer: PACE SWMI |
$19,376.56
|
| Rate for Payer: PHP Commercial |
$21,314.22
|
| Rate for Payer: PHP Medicare Advantage |
$19,376.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26,836.88
|
| Rate for Payer: Priority Health Medicare |
$19,376.56
|
| Rate for Payer: Priority Health Narrow Network |
$21,469.50
|
| Rate for Payer: Railroad Medicare Medicare |
$19,376.56
|
| Rate for Payer: UHC Medicare Advantage |
$19,957.86
|
| Rate for Payer: VA VA |
$19,376.56
|
|
|
SKIN ULCERS WITHOUT CC/MCC
|
Facility
IP
|
$10,434.24
|
|
|
Service Code
|
MS-DRG 594
|
| Min. Negotiated Rate |
$7,930.02 |
| Max. Negotiated Rate |
$10,434.24 |
| Rate for Payer: Aetna Medicare |
$8,347.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,434.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,434.24
|
| Rate for Payer: BCBS MAPPO |
$8,347.39
|
| Rate for Payer: BCN Medicare Advantage |
$8,347.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,347.39
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,347.39
|
| Rate for Payer: Mclaren Medicare |
$8,347.39
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,764.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,599.50
|
| Rate for Payer: PACE Medicare |
$7,930.02
|
| Rate for Payer: PACE SWMI |
$8,347.39
|
| Rate for Payer: PHP Commercial |
$9,182.13
|
| Rate for Payer: PHP Medicare Advantage |
$8,347.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,110.22
|
| Rate for Payer: Priority Health Medicare |
$8,347.39
|
| Rate for Payer: Priority Health Narrow Network |
$8,088.18
|
| Rate for Payer: Railroad Medicare Medicare |
$8,347.39
|
| Rate for Payer: UHC Medicare Advantage |
$8,597.81
|
| Rate for Payer: VA VA |
$8,347.39
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$36.27
|
|
|
Service Code
|
NDC 0409-6625-02
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.39 |
| Max. Negotiated Rate |
$36.27 |
| Rate for Payer: Aetna Commercial |
$32.64
|
| Rate for Payer: ASR ASR |
$35.18
|
| Rate for Payer: BCBS Trust/PPO |
$28.12
|
| Rate for Payer: BCN Commercial |
$28.12
|
| Rate for Payer: Cash Price |
$29.01
|
| Rate for Payer: Cofinity Commercial |
$34.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.02
|
| Rate for Payer: Healthscope Commercial |
$36.27
|
| Rate for Payer: Healthscope Whirlpool |
$35.18
|
| Rate for Payer: Mclaren Commercial |
$32.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.92
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$35.60
|
|
|
Service Code
|
NDC 0409-6625-30
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.92 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: ASR ASR |
$34.53
|
| Rate for Payer: BCBS Trust/PPO |
$27.60
|
| Rate for Payer: BCN Commercial |
$27.60
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cofinity Commercial |
$33.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.48
|
| Rate for Payer: Healthscope Commercial |
$35.60
|
| Rate for Payer: Healthscope Whirlpool |
$34.53
|
| Rate for Payer: Mclaren Commercial |
$32.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.33
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$35.60
|
|
|
Service Code
|
NDC 0409-6625-35
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.92 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: ASR ASR |
$34.53
|
| Rate for Payer: BCBS Trust/PPO |
$27.60
|
| Rate for Payer: BCN Commercial |
$27.60
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cofinity Commercial |
$33.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.48
|
| Rate for Payer: Healthscope Commercial |
$35.60
|
| Rate for Payer: Healthscope Whirlpool |
$34.53
|
| Rate for Payer: Mclaren Commercial |
$32.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.33
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$36.05
|
|
|
Service Code
|
NDC 51754-5001-5
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.24 |
| Max. Negotiated Rate |
$36.05 |
| Rate for Payer: Aetna Commercial |
$32.44
|
| Rate for Payer: ASR ASR |
$34.97
|
| Rate for Payer: BCBS Trust/PPO |
$27.95
|
| Rate for Payer: BCN Commercial |
$27.95
|
| Rate for Payer: Cash Price |
$28.84
|
| Rate for Payer: Cofinity Commercial |
$33.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.84
|
| Rate for Payer: Healthscope Commercial |
$36.05
|
| Rate for Payer: Healthscope Whirlpool |
$34.97
|
| Rate for Payer: Mclaren Commercial |
$32.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.72
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$35.16
|
|
|
Service Code
|
NDC 0409-6625-25
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.61 |
| Max. Negotiated Rate |
$35.16 |
| Rate for Payer: Aetna Commercial |
$31.64
|
| Rate for Payer: ASR ASR |
$34.11
|
| Rate for Payer: BCBS Trust/PPO |
$27.26
|
| Rate for Payer: BCN Commercial |
$27.26
|
| Rate for Payer: Cash Price |
$28.12
|
| Rate for Payer: Cofinity Commercial |
$33.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.13
|
| Rate for Payer: Healthscope Commercial |
$35.16
|
| Rate for Payer: Healthscope Whirlpool |
$34.11
|
| Rate for Payer: Mclaren Commercial |
$31.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.94
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
IP
|
$38.94
|
|
|
Service Code
|
NDC 51754-5001-1
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.26 |
| Max. Negotiated Rate |
$38.94 |
| Rate for Payer: Aetna Commercial |
$35.05
|
| Rate for Payer: ASR ASR |
$37.77
|
| Rate for Payer: BCBS Trust/PPO |
$30.19
|
| Rate for Payer: BCN Commercial |
$30.19
|
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: Cofinity Commercial |
$36.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.15
|
| Rate for Payer: Healthscope Commercial |
$38.94
|
| Rate for Payer: Healthscope Whirlpool |
$37.77
|
| Rate for Payer: Mclaren Commercial |
$35.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$34.27
|
|
|
SODIUM BICARBONATE 650 MG TABLET
|
Facility
IP
|
$277.30
|
|
|
Service Code
|
NDC 7733383110
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.11 |
| Max. Negotiated Rate |
$277.30 |
| Rate for Payer: Aetna Commercial |
$249.57
|
| Rate for Payer: ASR ASR |
$268.98
|
| Rate for Payer: BCBS Trust/PPO |
$214.99
|
| Rate for Payer: BCN Commercial |
$214.99
|
| Rate for Payer: Cash Price |
$221.84
|
| Rate for Payer: Cofinity Commercial |
$260.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.84
|
| Rate for Payer: Healthscope Commercial |
$277.30
|
| Rate for Payer: Healthscope Whirlpool |
$268.98
|
| Rate for Payer: Mclaren Commercial |
$249.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.02
|
|
|
SODIUM BICARBONATE 650 MG TABLET
|
Facility
IP
|
$159.80
|
|
|
Service Code
|
NDC 0223-1721-01
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.86 |
| Max. Negotiated Rate |
$159.80 |
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: ASR ASR |
$155.01
|
| Rate for Payer: BCBS Trust/PPO |
$123.89
|
| Rate for Payer: BCN Commercial |
$123.89
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$150.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$159.80
|
| Rate for Payer: Healthscope Whirlpool |
$155.01
|
| Rate for Payer: Mclaren Commercial |
$143.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$140.62
|
|
|
SODIUM BICARBONATE 650 MG TABLET
|
Facility
IP
|
$2.77
|
|
|
Service Code
|
NDC 7733383125
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: ASR ASR |
$2.69
|
| Rate for Payer: BCBS Trust/PPO |
$2.15
|
| Rate for Payer: BCN Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cofinity Commercial |
$2.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.22
|
| Rate for Payer: Healthscope Commercial |
$2.77
|
| Rate for Payer: Healthscope Whirlpool |
$2.69
|
| Rate for Payer: Mclaren Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.44
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE
|
Facility
IP
|
$61.19
|
|
|
Service Code
|
NDC 76329-3352-1
|
| Hospital Charge Code |
7309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.83 |
| Max. Negotiated Rate |
$61.19 |
| Rate for Payer: Aetna Commercial |
$55.07
|
| Rate for Payer: ASR ASR |
$59.35
|
| Rate for Payer: BCBS Trust/PPO |
$47.44
|
| Rate for Payer: BCN Commercial |
$47.44
|
| Rate for Payer: Cash Price |
$48.95
|
| Rate for Payer: Cofinity Commercial |
$57.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.95
|
| Rate for Payer: Healthscope Commercial |
$61.19
|
| Rate for Payer: Healthscope Whirlpool |
$59.35
|
| Rate for Payer: Mclaren Commercial |
$55.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$53.85
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE
|
Facility
IP
|
$40.94
|
|
|
Service Code
|
NDC 0409-6637-34
|
| Hospital Charge Code |
7309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.66 |
| Max. Negotiated Rate |
$40.94 |
| Rate for Payer: Aetna Commercial |
$36.85
|
| Rate for Payer: ASR ASR |
$39.71
|
| Rate for Payer: BCBS Trust/PPO |
$31.74
|
| Rate for Payer: BCN Commercial |
$31.74
|
| Rate for Payer: Cash Price |
$32.75
|
| Rate for Payer: Cofinity Commercial |
$38.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.75
|
| Rate for Payer: Healthscope Commercial |
$40.94
|
| Rate for Payer: Healthscope Whirlpool |
$39.71
|
| Rate for Payer: Mclaren Commercial |
$36.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.03
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE (CODE)
|
Facility
IP
|
$40.94
|
|
|
Service Code
|
NDC 0409-6637-34
|
| Hospital Charge Code |
163719
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.66 |
| Max. Negotiated Rate |
$40.94 |
| Rate for Payer: Aetna Commercial |
$36.85
|
| Rate for Payer: ASR ASR |
$39.71
|
| Rate for Payer: BCBS Trust/PPO |
$31.74
|
| Rate for Payer: BCN Commercial |
$31.74
|
| Rate for Payer: Cash Price |
$32.75
|
| Rate for Payer: Cofinity Commercial |
$38.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.75
|
| Rate for Payer: Healthscope Commercial |
$40.94
|
| Rate for Payer: Healthscope Whirlpool |
$39.71
|
| Rate for Payer: Mclaren Commercial |
$36.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.03
|
|
|
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN
|
Facility
IP
|
$51.84
|
|
|
Service Code
|
NDC 1011900738
|
| Hospital Charge Code |
165406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.29 |
| Max. Negotiated Rate |
$51.84 |
| Rate for Payer: Aetna Commercial |
$46.66
|
| Rate for Payer: ASR ASR |
$50.28
|
| Rate for Payer: BCBS Trust/PPO |
$40.19
|
| Rate for Payer: BCN Commercial |
$40.19
|
| Rate for Payer: Cash Price |
$41.47
|
| Rate for Payer: Cofinity Commercial |
$48.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.47
|
| Rate for Payer: Healthscope Commercial |
$51.84
|
| Rate for Payer: Healthscope Whirlpool |
$50.28
|
| Rate for Payer: Mclaren Commercial |
$46.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.62
|
|
|
SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN
|
Facility
IP
|
$51.84
|
|
|
Service Code
|
NDC 1011900252
|
| Hospital Charge Code |
165406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.29 |
| Max. Negotiated Rate |
$51.84 |
| Rate for Payer: Aetna Commercial |
$46.66
|
| Rate for Payer: ASR ASR |
$50.28
|
| Rate for Payer: BCBS Trust/PPO |
$40.19
|
| Rate for Payer: BCN Commercial |
$40.19
|
| Rate for Payer: Cash Price |
$41.47
|
| Rate for Payer: Cofinity Commercial |
$48.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.47
|
| Rate for Payer: Healthscope Commercial |
$51.84
|
| Rate for Payer: Healthscope Whirlpool |
$50.28
|
| Rate for Payer: Mclaren Commercial |
$46.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.62
|
|
|
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION
|
Facility
IP
|
$69.92
|
|
|
Service Code
|
NDC 0338-0043-04
|
| Hospital Charge Code |
7318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.94 |
| 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 |
$54.21
|
| Rate for Payer: BCN Commercial |
$54.21
|
| 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 |
$69.92
|
| Rate for Payer: Healthscope Whirlpool |
$67.82
|
| Rate for Payer: Mclaren Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.53
|
|
|
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL
|
Facility
IP
|
$5.28
|
|
|
Service Code
|
NDC 0904-3865-75
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$5.28 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: ASR ASR |
$5.12
|
| Rate for Payer: BCBS Trust/PPO |
$4.09
|
| Rate for Payer: BCN Commercial |
$4.09
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cofinity Commercial |
$4.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.22
|
| Rate for Payer: Healthscope Commercial |
$5.28
|
| Rate for Payer: Healthscope Whirlpool |
$5.12
|
| Rate for Payer: Mclaren Commercial |
$4.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.65
|
|
|
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL
|
Facility
IP
|
$5.94
|
|
|
Service Code
|
NDC 45802-357-58
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$5.94 |
| Rate for Payer: Aetna Commercial |
$5.35
|
| Rate for Payer: ASR ASR |
$5.76
|
| Rate for Payer: BCBS Trust/PPO |
$4.61
|
| Rate for Payer: BCN Commercial |
$4.61
|
| Rate for Payer: Cash Price |
$4.75
|
| Rate for Payer: Cofinity Commercial |
$5.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.75
|
| Rate for Payer: Healthscope Commercial |
$5.94
|
| Rate for Payer: Healthscope Whirlpool |
$5.76
|
| Rate for Payer: Mclaren Commercial |
$5.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.23
|
|
|
SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL
|
Facility
IP
|
$16.04
|
|
|
Service Code
|
NDC 187526003
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna Commercial |
$14.44
|
| Rate for Payer: ASR ASR |
$15.56
|
| Rate for Payer: BCBS Trust/PPO |
$12.44
|
| Rate for Payer: BCN Commercial |
$12.44
|
| Rate for Payer: Cash Price |
$12.83
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.83
|
| Rate for Payer: Healthscope Commercial |
$16.04
|
| Rate for Payer: Healthscope Whirlpool |
$15.56
|
| Rate for Payer: Mclaren Commercial |
$14.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.12
|
|
