|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$6,973.73
|
|
|
Service Code
|
APR-DRG 0523
|
| Min. Negotiated Rate |
$6,305.08 |
| Max. Negotiated Rate |
$6,973.73 |
| Rate for Payer: BCBS Complete |
$6,973.73
|
| Rate for Payer: Mclaren Medicaid |
$6,641.64
|
| Rate for Payer: Meridian Medicaid |
$6,973.73
|
| Rate for Payer: PHP Medicaid |
$6,305.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,641.64
|
| Rate for Payer: UHC Medicaid |
$6,641.64
|
| Rate for Payer: UHCCP Medicaid |
$6,641.64
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$18.50
|
|
|
Service Code
|
NDC 121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$18.50 |
| Rate for Payer: Aetna Commercial |
$16.65
|
| Rate for Payer: Aetna Medicare |
$6.84
|
| Rate for Payer: ASR ASR |
$17.94
|
| Rate for Payer: BCBS Complete |
$7.40
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$15.25
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.80
|
| Rate for Payer: Healthscope Commercial |
$17.94
|
| Rate for Payer: Healthscope Whirlpool |
$18.50
|
| Rate for Payer: Mclaren Commercial |
$16.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.72
|
| Rate for Payer: Nomi Health Commercial |
$15.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.21
|
| Rate for Payer: Priority Health Narrow Network |
$12.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.28
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$11.75
|
|
|
Service Code
|
NDC 904755773
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna Commercial |
$10.57
|
| Rate for Payer: Aetna Medicare |
$4.35
|
| Rate for Payer: ASR ASR |
$11.39
|
| Rate for Payer: BCBS Complete |
$4.70
|
| Rate for Payer: BCBS Trust/PPO |
$9.68
|
| Rate for Payer: BCN Commercial |
$9.68
|
| Rate for Payer: Cash Price |
$9.40
|
| Rate for Payer: Cofinity Commercial |
$11.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.40
|
| Rate for Payer: Healthscope Commercial |
$11.39
|
| Rate for Payer: Healthscope Whirlpool |
$11.74
|
| Rate for Payer: Mclaren Commercial |
$10.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.98
|
| Rate for Payer: Nomi Health Commercial |
$9.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$10.29
|
| Rate for Payer: Priority Health Narrow Network |
$8.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.34
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$18.50
|
|
|
Service Code
|
NDC 121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.87 |
| Max. Negotiated Rate |
$18.50 |
| Rate for Payer: Aetna Commercial |
$16.65
|
| Rate for Payer: ASR ASR |
$17.94
|
| Rate for Payer: BCBS Trust/PPO |
$15.19
|
| Rate for Payer: BCN Commercial |
$15.19
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.80
|
| Rate for Payer: Healthscope Commercial |
$17.94
|
| Rate for Payer: Healthscope Whirlpool |
$18.50
|
| Rate for Payer: Mclaren Commercial |
$16.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.72
|
| Rate for Payer: Nomi Health Commercial |
$15.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.28
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$11.75
|
|
|
Service Code
|
NDC 904755773
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna Commercial |
$10.57
|
| Rate for Payer: ASR ASR |
$11.39
|
| Rate for Payer: BCBS Trust/PPO |
$9.64
|
| Rate for Payer: BCN Commercial |
$9.64
|
| Rate for Payer: Cash Price |
$9.40
|
| Rate for Payer: Cofinity Commercial |
$11.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.40
|
| Rate for Payer: Healthscope Commercial |
$11.39
|
| Rate for Payer: Healthscope Whirlpool |
$11.74
|
| Rate for Payer: Mclaren Commercial |
$10.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.98
|
| Rate for Payer: Nomi Health Commercial |
$9.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.34
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$11.75
|
|
|
Service Code
|
NDC 904755762
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna Commercial |
$10.57
|
| Rate for Payer: ASR ASR |
$11.39
|
| Rate for Payer: BCBS Trust/PPO |
$9.64
|
| Rate for Payer: BCN Commercial |
$9.64
|
| Rate for Payer: Cash Price |
$9.40
|
| Rate for Payer: Cofinity Commercial |
$11.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.40
|
| Rate for Payer: Healthscope Commercial |
$11.39
|
| Rate for Payer: Healthscope Whirlpool |
$11.74
|
| Rate for Payer: Mclaren Commercial |
$10.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.98
|
| Rate for Payer: Nomi Health Commercial |
$9.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.34
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$11.75
|
|
|
Service Code
|
NDC 904755762
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna Commercial |
$10.57
|
| Rate for Payer: Aetna Medicare |
$4.35
|
| Rate for Payer: ASR ASR |
$11.39
|
| Rate for Payer: BCBS Complete |
$4.70
|
| Rate for Payer: BCBS Trust/PPO |
$9.68
|
| Rate for Payer: BCN Commercial |
$9.68
|
| Rate for Payer: Cash Price |
$9.40
|
| Rate for Payer: Cofinity Commercial |
$11.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.40
|
| Rate for Payer: Healthscope Commercial |
$11.39
|
| Rate for Payer: Healthscope Whirlpool |
$11.74
|
| Rate for Payer: Mclaren Commercial |
$10.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.98
|
| Rate for Payer: Nomi Health Commercial |
$9.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$10.29
|
| Rate for Payer: Priority Health Narrow Network |
$8.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.34
|
|
|
AMANTADINE HCL 100 MG TABLET
|
Facility
|
OP
|
$8.57
|
|
|
Service Code
|
NDC 832011189
|
| Hospital Charge Code |
20506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$8.57 |
| Rate for Payer: Aetna Commercial |
$7.72
|
| Rate for Payer: Aetna Medicare |
$3.17
|
| Rate for Payer: ASR ASR |
$8.32
|
| Rate for Payer: BCBS Complete |
$3.43
|
| Rate for Payer: BCBS Trust/PPO |
$7.07
|
| Rate for Payer: BCN Commercial |
$7.07
|
| Rate for Payer: Cash Price |
$6.86
|
| Rate for Payer: Cofinity Commercial |
$8.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.86
|
| Rate for Payer: Healthscope Commercial |
$8.32
|
| Rate for Payer: Healthscope Whirlpool |
$8.57
|
| Rate for Payer: Mclaren Commercial |
$7.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.29
|
| Rate for Payer: Nomi Health Commercial |
$7.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$7.51
|
| Rate for Payer: Priority Health Narrow Network |
$6.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.54
|
|
|
AMANTADINE HCL 100 MG TABLET
|
Facility
|
IP
|
$8.57
|
|
|
Service Code
|
NDC 832011189
|
| Hospital Charge Code |
20506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.43 |
| Max. Negotiated Rate |
$8.57 |
| Rate for Payer: Aetna Commercial |
$7.72
|
| Rate for Payer: ASR ASR |
$8.32
|
| Rate for Payer: BCBS Trust/PPO |
$7.04
|
| Rate for Payer: BCN Commercial |
$7.04
|
| Rate for Payer: Cash Price |
$6.86
|
| Rate for Payer: Cofinity Commercial |
$8.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.86
|
| Rate for Payer: Healthscope Commercial |
$8.32
|
| Rate for Payer: Healthscope Whirlpool |
$8.57
|
| Rate for Payer: Mclaren Commercial |
$7.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.29
|
| Rate for Payer: Nomi Health Commercial |
$7.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.54
|
|
|
AMANTADINE HCL 100 MG TABLET
|
Facility
|
IP
|
$857.28
|
|
|
Service Code
|
NDC 832011103
|
| Hospital Charge Code |
20506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$642.96 |
| Max. Negotiated Rate |
$857.28 |
| Rate for Payer: Aetna Commercial |
$771.55
|
| Rate for Payer: ASR ASR |
$831.56
|
| Rate for Payer: BCBS Trust/PPO |
$704.00
|
| Rate for Payer: BCN Commercial |
$704.00
|
| Rate for Payer: Cash Price |
$685.82
|
| Rate for Payer: Cofinity Commercial |
$805.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$685.82
|
| Rate for Payer: Healthscope Commercial |
$831.56
|
| Rate for Payer: Healthscope Whirlpool |
$857.28
|
| Rate for Payer: Mclaren Commercial |
$771.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$728.69
|
| Rate for Payer: Nomi Health Commercial |
$702.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$642.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$754.41
|
|
|
AMANTADINE HCL 100 MG TABLET
|
Facility
|
IP
|
$713.28
|
|
|
Service Code
|
NDC 832011100
|
| Hospital Charge Code |
20506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$534.96 |
| Max. Negotiated Rate |
$713.28 |
| Rate for Payer: Aetna Commercial |
$641.95
|
| Rate for Payer: ASR ASR |
$691.88
|
| Rate for Payer: BCBS Trust/PPO |
$585.75
|
| Rate for Payer: BCN Commercial |
$585.75
|
| Rate for Payer: Cash Price |
$570.62
|
| Rate for Payer: Cofinity Commercial |
$670.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$570.62
|
| Rate for Payer: Healthscope Commercial |
$691.88
|
| Rate for Payer: Healthscope Whirlpool |
$713.28
|
| Rate for Payer: Mclaren Commercial |
$641.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$606.29
|
| Rate for Payer: Nomi Health Commercial |
$584.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$534.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$627.69
|
|
|
AMANTADINE HCL 100 MG TABLET
|
Facility
|
OP
|
$713.28
|
|
|
Service Code
|
NDC 832011100
|
| Hospital Charge Code |
20506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$263.91 |
| Max. Negotiated Rate |
$713.28 |
| Rate for Payer: Aetna Commercial |
$641.95
|
| Rate for Payer: Aetna Medicare |
$263.91
|
| Rate for Payer: ASR ASR |
$691.88
|
| Rate for Payer: BCBS Complete |
$285.31
|
| Rate for Payer: BCBS Trust/PPO |
$588.10
|
| Rate for Payer: BCN Commercial |
$588.10
|
| Rate for Payer: Cash Price |
$570.62
|
| Rate for Payer: Cofinity Commercial |
$670.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$570.62
|
| Rate for Payer: Healthscope Commercial |
$691.88
|
| Rate for Payer: Healthscope Whirlpool |
$713.28
|
| Rate for Payer: Mclaren Commercial |
$641.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$570.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$606.29
|
| Rate for Payer: Nomi Health Commercial |
$584.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$534.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$624.98
|
| Rate for Payer: Priority Health Narrow Network |
$500.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$627.69
|
|
|
AMANTADINE HCL 100 MG TABLET
|
Facility
|
OP
|
$857.28
|
|
|
Service Code
|
NDC 832011103
|
| Hospital Charge Code |
20506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$317.19 |
| Max. Negotiated Rate |
$857.28 |
| Rate for Payer: Aetna Commercial |
$771.55
|
| Rate for Payer: Aetna Medicare |
$317.19
|
| Rate for Payer: ASR ASR |
$831.56
|
| Rate for Payer: BCBS Complete |
$342.91
|
| Rate for Payer: BCBS Trust/PPO |
$706.83
|
| Rate for Payer: BCN Commercial |
$706.83
|
| Rate for Payer: Cash Price |
$685.82
|
| Rate for Payer: Cofinity Commercial |
$805.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$685.82
|
| Rate for Payer: Healthscope Commercial |
$831.56
|
| Rate for Payer: Healthscope Whirlpool |
$857.28
|
| Rate for Payer: Mclaren Commercial |
$771.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$685.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$728.69
|
| Rate for Payer: Nomi Health Commercial |
$702.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$642.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$751.15
|
| Rate for Payer: Priority Health Narrow Network |
$600.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$754.41
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$167.77
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$167.76 |
| Rate for Payer: Aetna Commercial |
$150.99
|
| Rate for Payer: Aetna Medicare |
$62.07
|
| Rate for Payer: ASR ASR |
$162.73
|
| Rate for Payer: BCBS Complete |
$67.11
|
| Rate for Payer: BCBS Trust/PPO |
$138.32
|
| Rate for Payer: BCN Commercial |
$138.32
|
| Rate for Payer: Cash Price |
$134.21
|
| Rate for Payer: Cash Price |
$134.21
|
| Rate for Payer: Cofinity Commercial |
$157.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.21
|
| Rate for Payer: Healthscope Commercial |
$162.73
|
| Rate for Payer: Healthscope Whirlpool |
$167.76
|
| Rate for Payer: Mclaren Commercial |
$150.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.60
|
| Rate for Payer: Nomi Health Commercial |
$137.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$10.80
|
| Rate for Payer: Priority Health Narrow Network |
$8.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$147.63
|
|
|
AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$167.77
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
407
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.82 |
| Max. Negotiated Rate |
$167.76 |
| Rate for Payer: Aetna Commercial |
$150.99
|
| Rate for Payer: ASR ASR |
$162.73
|
| Rate for Payer: BCBS Trust/PPO |
$137.77
|
| Rate for Payer: BCN Commercial |
$137.77
|
| Rate for Payer: Cash Price |
$134.21
|
| Rate for Payer: Cofinity Commercial |
$157.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.21
|
| Rate for Payer: Healthscope Commercial |
$162.73
|
| Rate for Payer: Healthscope Whirlpool |
$167.76
|
| Rate for Payer: Mclaren Commercial |
$150.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.60
|
| Rate for Payer: Nomi Health Commercial |
$137.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$147.63
|
|
|
AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$33.20
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
113386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$33.20 |
| Rate for Payer: Aetna Commercial |
$29.88
|
| Rate for Payer: Aetna Medicare |
$12.28
|
| Rate for Payer: ASR ASR |
$32.20
|
| Rate for Payer: BCBS Complete |
$13.28
|
| Rate for Payer: BCBS Trust/PPO |
$27.37
|
| Rate for Payer: BCN Commercial |
$27.37
|
| Rate for Payer: Cash Price |
$26.56
|
| Rate for Payer: Cash Price |
$26.56
|
| Rate for Payer: Cofinity Commercial |
$31.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.56
|
| Rate for Payer: Healthscope Commercial |
$32.20
|
| Rate for Payer: Healthscope Whirlpool |
$33.20
|
| Rate for Payer: Mclaren Commercial |
$29.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.22
|
| Rate for Payer: Nomi Health Commercial |
$27.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$10.80
|
| Rate for Payer: Priority Health Narrow Network |
$8.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.21
|
|
|
AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$33.20
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
113386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.90 |
| Max. Negotiated Rate |
$33.20 |
| Rate for Payer: Aetna Commercial |
$29.88
|
| Rate for Payer: ASR ASR |
$32.20
|
| Rate for Payer: BCBS Trust/PPO |
$27.26
|
| Rate for Payer: BCN Commercial |
$27.26
|
| Rate for Payer: Cash Price |
$26.56
|
| Rate for Payer: Cofinity Commercial |
$31.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.56
|
| Rate for Payer: Healthscope Commercial |
$32.20
|
| Rate for Payer: Healthscope Whirlpool |
$33.20
|
| Rate for Payer: Mclaren Commercial |
$29.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.22
|
| Rate for Payer: Nomi Health Commercial |
$27.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.21
|
|
|
AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
|
OP
|
$143.74
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$143.74 |
| Rate for Payer: Aetna Commercial |
$129.36
|
| Rate for Payer: Aetna Medicare |
$53.18
|
| Rate for Payer: ASR ASR |
$139.42
|
| Rate for Payer: BCBS Complete |
$57.49
|
| Rate for Payer: BCBS Trust/PPO |
$118.51
|
| Rate for Payer: BCN Commercial |
$118.51
|
| Rate for Payer: Cash Price |
$114.99
|
| Rate for Payer: Cash Price |
$114.99
|
| Rate for Payer: Cofinity Commercial |
$135.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.99
|
| Rate for Payer: Healthscope Commercial |
$139.42
|
| Rate for Payer: Healthscope Whirlpool |
$143.74
|
| Rate for Payer: Mclaren Commercial |
$129.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$114.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.17
|
| Rate for Payer: Nomi Health Commercial |
$117.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.80
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.62
|
| Rate for Payer: Priority Health Narrow Network |
$2.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$126.49
|
|
|
AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
|
IP
|
$143.74
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$143.74 |
| Rate for Payer: Aetna Commercial |
$129.36
|
| Rate for Payer: ASR ASR |
$139.42
|
| Rate for Payer: BCBS Trust/PPO |
$118.04
|
| Rate for Payer: BCN Commercial |
$118.04
|
| Rate for Payer: Cash Price |
$114.99
|
| Rate for Payer: Cofinity Commercial |
$135.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.99
|
| Rate for Payer: Healthscope Commercial |
$139.42
|
| Rate for Payer: Healthscope Whirlpool |
$143.74
|
| Rate for Payer: Mclaren Commercial |
$129.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$122.17
|
| Rate for Payer: Nomi Health Commercial |
$117.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$126.49
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
|
IP
|
$327.75
|
|
|
Service Code
|
NDC 68084037101
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.81 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Aetna Commercial |
$294.98
|
| Rate for Payer: ASR ASR |
$317.92
|
| Rate for Payer: BCBS Trust/PPO |
$269.15
|
| Rate for Payer: BCN Commercial |
$269.15
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cofinity Commercial |
$308.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.20
|
| Rate for Payer: Healthscope Commercial |
$317.92
|
| Rate for Payer: Healthscope Whirlpool |
$327.75
|
| Rate for Payer: Mclaren Commercial |
$294.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.59
|
| Rate for Payer: Nomi Health Commercial |
$268.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$288.42
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
|
OP
|
$327.75
|
|
|
Service Code
|
NDC 68084037101
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.27 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Aetna Commercial |
$294.98
|
| Rate for Payer: Aetna Medicare |
$121.27
|
| Rate for Payer: ASR ASR |
$317.92
|
| Rate for Payer: BCBS Complete |
$131.10
|
| Rate for Payer: BCBS Trust/PPO |
$270.23
|
| Rate for Payer: BCN Commercial |
$270.23
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cofinity Commercial |
$308.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.20
|
| Rate for Payer: Healthscope Commercial |
$317.92
|
| Rate for Payer: Healthscope Whirlpool |
$327.75
|
| Rate for Payer: Mclaren Commercial |
$294.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$262.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.59
|
| Rate for Payer: Nomi Health Commercial |
$268.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$287.17
|
| Rate for Payer: Priority Health Narrow Network |
$229.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$288.42
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
|
OP
|
$2.20
|
|
|
Service Code
|
NDC 245014789
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$1.98
|
| Rate for Payer: Aetna Medicare |
$0.81
|
| Rate for Payer: ASR ASR |
$2.13
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: BCBS Trust/PPO |
$1.81
|
| Rate for Payer: BCN Commercial |
$1.81
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.76
|
| Rate for Payer: Healthscope Commercial |
$2.13
|
| Rate for Payer: Healthscope Whirlpool |
$2.19
|
| Rate for Payer: Mclaren Commercial |
$1.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.87
|
| Rate for Payer: Nomi Health Commercial |
$1.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.65
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.92
|
| Rate for Payer: Priority Health Narrow Network |
$1.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.93
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
|
OP
|
$327.75
|
|
|
Service Code
|
NDC 68084037111
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.27 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Aetna Commercial |
$294.98
|
| Rate for Payer: Aetna Medicare |
$121.27
|
| Rate for Payer: ASR ASR |
$317.92
|
| Rate for Payer: BCBS Complete |
$131.10
|
| Rate for Payer: BCBS Trust/PPO |
$270.23
|
| Rate for Payer: BCN Commercial |
$270.23
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cofinity Commercial |
$308.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.20
|
| Rate for Payer: Healthscope Commercial |
$317.92
|
| Rate for Payer: Healthscope Whirlpool |
$327.75
|
| Rate for Payer: Mclaren Commercial |
$294.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$262.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.59
|
| Rate for Payer: Nomi Health Commercial |
$268.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$287.17
|
| Rate for Payer: Priority Health Narrow Network |
$229.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$288.42
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
|
IP
|
$2.20
|
|
|
Service Code
|
NDC 245014789
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$1.98
|
| Rate for Payer: ASR ASR |
$2.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.80
|
| Rate for Payer: BCN Commercial |
$1.80
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.76
|
| Rate for Payer: Healthscope Commercial |
$2.13
|
| Rate for Payer: Healthscope Whirlpool |
$2.19
|
| Rate for Payer: Mclaren Commercial |
$1.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.87
|
| Rate for Payer: Nomi Health Commercial |
$1.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.93
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
|
IP
|
$327.75
|
|
|
Service Code
|
NDC 68084037111
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.81 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Aetna Commercial |
$294.98
|
| Rate for Payer: ASR ASR |
$317.92
|
| Rate for Payer: BCBS Trust/PPO |
$269.15
|
| Rate for Payer: BCN Commercial |
$269.15
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cofinity Commercial |
$308.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.20
|
| Rate for Payer: Healthscope Commercial |
$317.92
|
| Rate for Payer: Healthscope Whirlpool |
$327.75
|
| Rate for Payer: Mclaren Commercial |
$294.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.59
|
| Rate for Payer: Nomi Health Commercial |
$268.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$288.42
|
|
