|
VIVONEX RTF CONTINUOUS FEED
|
Facility
IP
|
$14.80
|
|
|
Service Code
|
NDC 4390036250
|
| Hospital Charge Code |
168947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$11.47
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF CYCLIC FEED
|
Facility
IP
|
$6,408.40
|
|
|
Service Code
|
NDC 9900-0005-76
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,485.88 |
| Max. Negotiated Rate |
$6,408.40 |
| Rate for Payer: Aetna Commercial |
$5,767.56
|
| Rate for Payer: ASR ASR |
$6,216.15
|
| Rate for Payer: BCBS Trust/PPO |
$4,968.43
|
| Rate for Payer: BCN Commercial |
$4,968.43
|
| Rate for Payer: Cash Price |
$5,126.72
|
| Rate for Payer: Cofinity Commercial |
$6,023.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,126.72
|
| Rate for Payer: Healthscope Commercial |
$6,408.40
|
| Rate for Payer: Healthscope Whirlpool |
$6,216.15
|
| Rate for Payer: Mclaren Commercial |
$5,767.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,447.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,485.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,639.39
|
|
|
VIVONEX RTF CYCLIC FEED
|
Facility
IP
|
$14.80
|
|
|
Service Code
|
NDC 4390036250
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$11.47
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
IP
|
$6,408.40
|
|
|
Service Code
|
NDC 9900-0005-76
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,485.88 |
| Max. Negotiated Rate |
$6,408.40 |
| Rate for Payer: Aetna Commercial |
$5,767.56
|
| Rate for Payer: ASR ASR |
$6,216.15
|
| Rate for Payer: BCBS Trust/PPO |
$4,968.43
|
| Rate for Payer: BCN Commercial |
$4,968.43
|
| Rate for Payer: Cash Price |
$5,126.72
|
| Rate for Payer: Cofinity Commercial |
$6,023.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,126.72
|
| Rate for Payer: Healthscope Commercial |
$6,408.40
|
| Rate for Payer: Healthscope Whirlpool |
$6,216.15
|
| Rate for Payer: Mclaren Commercial |
$5,767.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,447.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,485.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,639.39
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
IP
|
$14.80
|
|
|
Service Code
|
NDC 4390036250
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$11.47
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
WARFARIN 1 MG TABLET
|
Facility
IP
|
$361.90
|
|
|
Service Code
|
NDC 0832-1211-01
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.33 |
| Max. Negotiated Rate |
$361.90 |
| Rate for Payer: Aetna Commercial |
$325.71
|
| Rate for Payer: ASR ASR |
$351.04
|
| Rate for Payer: BCBS Trust/PPO |
$280.58
|
| Rate for Payer: BCN Commercial |
$280.58
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$340.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.52
|
| Rate for Payer: Healthscope Commercial |
$361.90
|
| Rate for Payer: Healthscope Whirlpool |
$351.04
|
| Rate for Payer: Mclaren Commercial |
$325.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$307.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$318.47
|
|
|
WARFARIN 1 MG TABLET
|
Facility
IP
|
$3.62
|
|
|
Service Code
|
NDC 0832-1211-89
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: ASR ASR |
$3.51
|
| Rate for Payer: BCBS Trust/PPO |
$2.81
|
| Rate for Payer: BCN Commercial |
$2.81
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.90
|
| Rate for Payer: Healthscope Commercial |
$3.62
|
| Rate for Payer: Healthscope Whirlpool |
$3.51
|
| Rate for Payer: Mclaren Commercial |
$3.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.19
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
IP
|
$3.62
|
|
|
Service Code
|
NDC 0832-1213-89
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$3.62 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: ASR ASR |
$3.51
|
| Rate for Payer: BCBS Trust/PPO |
$2.81
|
| Rate for Payer: BCN Commercial |
$2.81
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.90
|
| Rate for Payer: Healthscope Commercial |
$3.62
|
| Rate for Payer: Healthscope Whirlpool |
$3.51
|
| Rate for Payer: Mclaren Commercial |
$3.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.19
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
IP
|
$361.90
|
|
|
Service Code
|
NDC 0832-1213-01
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.33 |
| Max. Negotiated Rate |
$361.90 |
| Rate for Payer: Aetna Commercial |
$325.71
|
| Rate for Payer: ASR ASR |
$351.04
|
| Rate for Payer: BCBS Trust/PPO |
$280.58
|
| Rate for Payer: BCN Commercial |
$280.58
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$340.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.52
|
| Rate for Payer: Healthscope Commercial |
$361.90
|
| Rate for Payer: Healthscope Whirlpool |
$351.04
|
| Rate for Payer: Mclaren Commercial |
$325.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$307.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$318.47
|
|
|
WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION
|
Facility
IP
|
$39.75
|
|
|
Service Code
|
NDC 0409-3977-03
|
| Hospital Charge Code |
864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$39.75 |
| Rate for Payer: Aetna Commercial |
$35.78
|
| Rate for Payer: ASR ASR |
$38.56
|
| Rate for Payer: BCBS Trust/PPO |
$30.82
|
| Rate for Payer: BCN Commercial |
$30.82
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cofinity Commercial |
$37.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.80
|
| Rate for Payer: Healthscope Commercial |
$39.75
|
| Rate for Payer: Healthscope Whirlpool |
$38.56
|
| Rate for Payer: Mclaren Commercial |
$35.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$34.98
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
IP
|
$18.11
|
|
|
Service Code
|
NDC 63323-185-10
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.68 |
| Max. Negotiated Rate |
$18.11 |
| Rate for Payer: Aetna Commercial |
$16.30
|
| Rate for Payer: ASR ASR |
$17.57
|
| Rate for Payer: BCBS Trust/PPO |
$14.04
|
| Rate for Payer: BCN Commercial |
$14.04
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.49
|
| Rate for Payer: Healthscope Commercial |
$18.11
|
| Rate for Payer: Healthscope Whirlpool |
$17.57
|
| Rate for Payer: Mclaren Commercial |
$16.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.94
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
IP
|
$15.08
|
|
|
Service Code
|
NDC 0409-4887-23
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna Commercial |
$13.57
|
| Rate for Payer: ASR ASR |
$14.63
|
| Rate for Payer: BCBS Trust/PPO |
$11.69
|
| Rate for Payer: BCN Commercial |
$11.69
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: Healthscope Whirlpool |
$14.63
|
| Rate for Payer: Mclaren Commercial |
$13.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.27
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
IP
|
$27.55
|
|
|
Service Code
|
NDC 0409-4887-50
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Aetna Commercial |
$24.80
|
| Rate for Payer: ASR ASR |
$26.72
|
| Rate for Payer: BCBS Trust/PPO |
$21.36
|
| Rate for Payer: BCN Commercial |
$21.36
|
| Rate for Payer: Cash Price |
$22.04
|
| Rate for Payer: Cofinity Commercial |
$25.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.04
|
| Rate for Payer: Healthscope Commercial |
$27.55
|
| Rate for Payer: Healthscope Whirlpool |
$26.72
|
| Rate for Payer: Mclaren Commercial |
$24.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.24
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
IP
|
$14.00
|
|
|
Service Code
|
NDC 0409-4887-10
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$12.60
|
| Rate for Payer: ASR ASR |
$13.58
|
| Rate for Payer: BCBS Trust/PPO |
$10.85
|
| Rate for Payer: BCN Commercial |
$10.85
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.20
|
| Rate for Payer: Healthscope Commercial |
$14.00
|
| Rate for Payer: Healthscope Whirlpool |
$13.58
|
| Rate for Payer: Mclaren Commercial |
$12.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.32
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
IP
|
$23.67
|
|
|
Service Code
|
NDC 63323-185-20
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$23.67 |
| Rate for Payer: Aetna Commercial |
$21.30
|
| Rate for Payer: ASR ASR |
$22.96
|
| Rate for Payer: BCBS Trust/PPO |
$18.35
|
| Rate for Payer: BCN Commercial |
$18.35
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cofinity Commercial |
$22.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Healthscope Commercial |
$23.67
|
| Rate for Payer: Healthscope Whirlpool |
$22.96
|
| Rate for Payer: Mclaren Commercial |
$21.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.83
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
IP
|
$20.24
|
|
|
Service Code
|
NDC 63323-185-04
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: BCBS Trust/PPO |
$15.69
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
IP
|
$15.08
|
|
|
Service Code
|
NDC 0409-4887-20
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna Commercial |
$13.57
|
| Rate for Payer: ASR ASR |
$14.63
|
| Rate for Payer: BCBS Trust/PPO |
$11.69
|
| Rate for Payer: BCN Commercial |
$11.69
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: Healthscope Whirlpool |
$14.63
|
| Rate for Payer: Mclaren Commercial |
$13.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.27
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
IP
|
$20.24
|
|
|
Service Code
|
NDC 63323-185-05
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: BCBS Trust/PPO |
$15.69
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
IP
|
$47.85
|
|
|
Service Code
|
NDC 0338-0013-04
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.50 |
| Max. Negotiated Rate |
$47.85 |
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: ASR ASR |
$46.41
|
| Rate for Payer: BCBS Trust/PPO |
$37.10
|
| Rate for Payer: BCN Commercial |
$37.10
|
| Rate for Payer: Cash Price |
$38.28
|
| Rate for Payer: Cofinity Commercial |
$44.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.28
|
| Rate for Payer: Healthscope Commercial |
$47.85
|
| Rate for Payer: Healthscope Whirlpool |
$46.41
|
| Rate for Payer: Mclaren Commercial |
$43.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$40.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.11
|
|
|
WHITE PETROLATUM 43 % TOPICAL OINTMENT
|
Facility
IP
|
$14.87
|
|
|
Service Code
|
NDC 53329-773-14
|
| Hospital Charge Code |
118982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$14.87 |
| Rate for Payer: Aetna Commercial |
$13.38
|
| Rate for Payer: ASR ASR |
$14.42
|
| Rate for Payer: BCBS Trust/PPO |
$11.53
|
| Rate for Payer: BCN Commercial |
$11.53
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Cofinity Commercial |
$13.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.90
|
| Rate for Payer: Healthscope Commercial |
$14.87
|
| Rate for Payer: Healthscope Whirlpool |
$14.42
|
| Rate for Payer: Mclaren Commercial |
$13.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.09
|
|
|
WHITE PETROLATUM 57.7 %-MINERAL OIL 31.9 % EYE OINTMENT
|
Facility
IP
|
$24.64
|
|
|
Service Code
|
NDC 6373614308
|
| Hospital Charge Code |
175688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Aetna Commercial |
$22.18
|
| Rate for Payer: ASR ASR |
$23.90
|
| Rate for Payer: BCBS Trust/PPO |
$19.10
|
| Rate for Payer: BCN Commercial |
$19.10
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$23.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$24.64
|
| Rate for Payer: Healthscope Whirlpool |
$23.90
|
| Rate for Payer: Mclaren Commercial |
$22.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.68
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT
|
Facility
IP
|
$31.81
|
|
|
Service Code
|
NDC 0023-0312-04
|
| Hospital Charge Code |
117955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.27 |
| Max. Negotiated Rate |
$31.81 |
| Rate for Payer: Aetna Commercial |
$28.63
|
| Rate for Payer: ASR ASR |
$30.86
|
| Rate for Payer: BCBS Trust/PPO |
$24.66
|
| Rate for Payer: BCN Commercial |
$24.66
|
| Rate for Payer: Cash Price |
$25.45
|
| Rate for Payer: Cofinity Commercial |
$29.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.45
|
| Rate for Payer: Healthscope Commercial |
$31.81
|
| Rate for Payer: Healthscope Whirlpool |
$30.86
|
| Rate for Payer: Mclaren Commercial |
$28.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.99
|
|
|
WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT
|
Facility
IP
|
$22.51
|
|
|
Service Code
|
NDC 0904-6488-38
|
| Hospital Charge Code |
117765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.76 |
| Max. Negotiated Rate |
$22.51 |
| Rate for Payer: Aetna Commercial |
$20.26
|
| Rate for Payer: ASR ASR |
$21.83
|
| Rate for Payer: BCBS Trust/PPO |
$17.45
|
| Rate for Payer: BCN Commercial |
$17.45
|
| Rate for Payer: Cash Price |
$18.01
|
| Rate for Payer: Cofinity Commercial |
$21.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.01
|
| Rate for Payer: Healthscope Commercial |
$22.51
|
| Rate for Payer: Healthscope Whirlpool |
$21.83
|
| Rate for Payer: Mclaren Commercial |
$20.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.81
|
|
|
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC
|
Facility
IP
|
$38,537.98
|
|
|
Service Code
|
MS-DRG 464
|
| Min. Negotiated Rate |
$25,737.39 |
| Max. Negotiated Rate |
$38,537.98 |
| Rate for Payer: Aetna Medicare |
$27,091.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33,864.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33,864.99
|
| Rate for Payer: BCBS MAPPO |
$27,091.99
|
| Rate for Payer: BCN Medicare Advantage |
$27,091.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27,091.99
|
| Rate for Payer: Humana Choice PPO Medicare |
$27,091.99
|
| Rate for Payer: Mclaren Medicare |
$27,091.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$28,446.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31,155.79
|
| Rate for Payer: PACE Medicare |
$25,737.39
|
| Rate for Payer: PACE SWMI |
$27,091.99
|
| Rate for Payer: PHP Commercial |
$29,801.19
|
| Rate for Payer: PHP Medicare Advantage |
$27,091.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38,537.98
|
| Rate for Payer: Priority Health Medicare |
$27,091.99
|
| Rate for Payer: Priority Health Narrow Network |
$30,830.38
|
| Rate for Payer: Railroad Medicare Medicare |
$27,091.99
|
| Rate for Payer: UHC Medicare Advantage |
$27,904.75
|
| Rate for Payer: VA VA |
$27,091.99
|
|
|
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC
|
Facility
IP
|
$72,721.91
|
|
|
Service Code
|
MS-DRG 463
|
| Min. Negotiated Rate |
$47,150.46 |
| Max. Negotiated Rate |
$72,721.91 |
| Rate for Payer: Aetna Medicare |
$49,632.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62,040.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62,040.08
|
| Rate for Payer: BCBS MAPPO |
$49,632.06
|
| Rate for Payer: BCN Medicare Advantage |
$49,632.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49,632.06
|
| Rate for Payer: Humana Choice PPO Medicare |
$49,632.06
|
| Rate for Payer: Mclaren Medicare |
$49,632.06
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$52,113.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57,076.87
|
| Rate for Payer: PACE Medicare |
$47,150.46
|
| Rate for Payer: PACE SWMI |
$49,632.06
|
| Rate for Payer: PHP Commercial |
$54,595.27
|
| Rate for Payer: PHP Medicare Advantage |
$49,632.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$72,721.91
|
| Rate for Payer: Priority Health Medicare |
$49,632.06
|
| Rate for Payer: Priority Health Narrow Network |
$58,177.53
|
| Rate for Payer: Railroad Medicare Medicare |
$49,632.06
|
| Rate for Payer: UHC Medicare Advantage |
$51,121.02
|
| Rate for Payer: VA VA |
$49,632.06
|
|
