|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$94.11
|
|
|
Service Code
|
NDC 63323088406
|
| Hospital Charge Code |
7351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.58 |
| Max. Negotiated Rate |
$94.11 |
| Rate for Payer: Aetna Commercial |
$84.69
|
| Rate for Payer: ASR ASR |
$91.28
|
| Rate for Payer: BCBS Trust/PPO |
$77.28
|
| Rate for Payer: BCN Commercial |
$77.28
|
| Rate for Payer: Cash Price |
$75.28
|
| Rate for Payer: Cofinity Commercial |
$88.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.28
|
| Rate for Payer: Healthscope Commercial |
$91.28
|
| Rate for Payer: Healthscope Whirlpool |
$94.11
|
| Rate for Payer: Mclaren Commercial |
$84.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.99
|
| Rate for Payer: Nomi Health Commercial |
$77.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$70.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$82.81
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
NDC 63323088101
|
| Hospital Charge Code |
7351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.69 |
| Max. Negotiated Rate |
$237.00 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Aetna Medicare |
$87.69
|
| Rate for Payer: ASR ASR |
$229.89
|
| Rate for Payer: BCBS Complete |
$94.80
|
| Rate for Payer: BCBS Trust/PPO |
$195.41
|
| Rate for Payer: BCN Commercial |
$195.41
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Cofinity Commercial |
$222.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.60
|
| Rate for Payer: Healthscope Commercial |
$229.89
|
| Rate for Payer: Healthscope Whirlpool |
$237.00
|
| Rate for Payer: Mclaren Commercial |
$213.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$189.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.45
|
| Rate for Payer: Nomi Health Commercial |
$194.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$177.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$207.66
|
| Rate for Payer: Priority Health Narrow Network |
$166.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$208.56
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
OP
|
$31.26
|
|
|
Service Code
|
NDC 904632078
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$31.25 |
| Rate for Payer: Aetna Commercial |
$28.13
|
| Rate for Payer: Aetna Medicare |
$11.56
|
| Rate for Payer: ASR ASR |
$30.32
|
| Rate for Payer: BCBS Complete |
$12.50
|
| Rate for Payer: BCBS Trust/PPO |
$25.77
|
| Rate for Payer: BCN Commercial |
$25.77
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cofinity Commercial |
$29.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.00
|
| Rate for Payer: Healthscope Commercial |
$30.32
|
| Rate for Payer: Healthscope Whirlpool |
$31.25
|
| Rate for Payer: Mclaren Commercial |
$28.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.57
|
| Rate for Payer: Nomi Health Commercial |
$25.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$27.39
|
| Rate for Payer: Priority Health Narrow Network |
$21.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.50
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
OP
|
$31.26
|
|
|
Service Code
|
NDC 536741551
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$31.25 |
| Rate for Payer: Aetna Commercial |
$28.13
|
| Rate for Payer: Aetna Medicare |
$11.56
|
| Rate for Payer: ASR ASR |
$30.32
|
| Rate for Payer: BCBS Complete |
$12.50
|
| Rate for Payer: BCBS Trust/PPO |
$25.77
|
| Rate for Payer: BCN Commercial |
$25.77
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cofinity Commercial |
$29.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.00
|
| Rate for Payer: Healthscope Commercial |
$30.32
|
| Rate for Payer: Healthscope Whirlpool |
$31.25
|
| Rate for Payer: Mclaren Commercial |
$28.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.57
|
| Rate for Payer: Nomi Health Commercial |
$25.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$27.39
|
| Rate for Payer: Priority Health Narrow Network |
$21.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.50
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
IP
|
$56.26
|
|
|
Service Code
|
NDC 132020142
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.19 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Aetna Commercial |
$50.63
|
| Rate for Payer: ASR ASR |
$54.57
|
| Rate for Payer: BCBS Trust/PPO |
$46.20
|
| Rate for Payer: BCN Commercial |
$46.20
|
| Rate for Payer: Cash Price |
$45.01
|
| Rate for Payer: Cofinity Commercial |
$52.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.01
|
| Rate for Payer: Healthscope Commercial |
$54.57
|
| Rate for Payer: Healthscope Whirlpool |
$56.26
|
| Rate for Payer: Mclaren Commercial |
$50.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.82
|
| Rate for Payer: Nomi Health Commercial |
$46.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.51
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
IP
|
$31.26
|
|
|
Service Code
|
NDC 904632078
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$31.25 |
| Rate for Payer: Aetna Commercial |
$28.13
|
| Rate for Payer: ASR ASR |
$30.32
|
| Rate for Payer: BCBS Trust/PPO |
$25.67
|
| Rate for Payer: BCN Commercial |
$25.67
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cofinity Commercial |
$29.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.00
|
| Rate for Payer: Healthscope Commercial |
$30.32
|
| Rate for Payer: Healthscope Whirlpool |
$31.25
|
| Rate for Payer: Mclaren Commercial |
$28.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.57
|
| Rate for Payer: Nomi Health Commercial |
$25.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.50
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
OP
|
$56.26
|
|
|
Service Code
|
NDC 132020142
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.82 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Aetna Commercial |
$50.63
|
| Rate for Payer: Aetna Medicare |
$20.82
|
| Rate for Payer: ASR ASR |
$54.57
|
| Rate for Payer: BCBS Complete |
$22.50
|
| Rate for Payer: BCBS Trust/PPO |
$46.39
|
| Rate for Payer: BCN Commercial |
$46.39
|
| Rate for Payer: Cash Price |
$45.01
|
| Rate for Payer: Cofinity Commercial |
$52.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.01
|
| Rate for Payer: Healthscope Commercial |
$54.57
|
| Rate for Payer: Healthscope Whirlpool |
$56.26
|
| Rate for Payer: Mclaren Commercial |
$50.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.82
|
| Rate for Payer: Nomi Health Commercial |
$46.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.19
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$49.29
|
| Rate for Payer: Priority Health Narrow Network |
$39.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.51
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
OP
|
$34.38
|
|
|
Service Code
|
NDC 132020140
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$34.38 |
| Rate for Payer: Aetna Commercial |
$30.94
|
| Rate for Payer: Aetna Medicare |
$12.72
|
| Rate for Payer: ASR ASR |
$33.35
|
| Rate for Payer: BCBS Complete |
$13.75
|
| Rate for Payer: BCBS Trust/PPO |
$28.35
|
| Rate for Payer: BCN Commercial |
$28.35
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cofinity Commercial |
$32.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.50
|
| Rate for Payer: Healthscope Commercial |
$33.35
|
| Rate for Payer: Healthscope Whirlpool |
$34.38
|
| Rate for Payer: Mclaren Commercial |
$30.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.22
|
| Rate for Payer: Nomi Health Commercial |
$28.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$30.12
|
| Rate for Payer: Priority Health Narrow Network |
$24.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.26
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
OP
|
$15.63
|
|
|
Service Code
|
NDC 96295012751
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$15.63 |
| Rate for Payer: Aetna Commercial |
$14.07
|
| Rate for Payer: Aetna Medicare |
$5.78
|
| Rate for Payer: ASR ASR |
$15.16
|
| Rate for Payer: BCBS Complete |
$6.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.89
|
| Rate for Payer: BCN Commercial |
$12.89
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cofinity Commercial |
$14.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.50
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Healthscope Whirlpool |
$15.63
|
| Rate for Payer: Mclaren Commercial |
$14.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.28
|
| Rate for Payer: Nomi Health Commercial |
$12.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$13.69
|
| Rate for Payer: Priority Health Narrow Network |
$10.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.75
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
IP
|
$31.26
|
|
|
Service Code
|
NDC 536741551
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$31.25 |
| Rate for Payer: Aetna Commercial |
$28.13
|
| Rate for Payer: ASR ASR |
$30.32
|
| Rate for Payer: BCBS Trust/PPO |
$25.67
|
| Rate for Payer: BCN Commercial |
$25.67
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cofinity Commercial |
$29.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.00
|
| Rate for Payer: Healthscope Commercial |
$30.32
|
| Rate for Payer: Healthscope Whirlpool |
$31.25
|
| Rate for Payer: Mclaren Commercial |
$28.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.57
|
| Rate for Payer: Nomi Health Commercial |
$25.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.50
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
IP
|
$34.38
|
|
|
Service Code
|
NDC 132020140
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.79 |
| Max. Negotiated Rate |
$34.38 |
| Rate for Payer: Aetna Commercial |
$30.94
|
| Rate for Payer: ASR ASR |
$33.35
|
| Rate for Payer: BCBS Trust/PPO |
$28.23
|
| Rate for Payer: BCN Commercial |
$28.23
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cofinity Commercial |
$32.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.50
|
| Rate for Payer: Healthscope Commercial |
$33.35
|
| Rate for Payer: Healthscope Whirlpool |
$34.38
|
| Rate for Payer: Mclaren Commercial |
$30.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.22
|
| Rate for Payer: Nomi Health Commercial |
$28.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.26
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA
|
Facility
|
IP
|
$15.63
|
|
|
Service Code
|
NDC 96295012751
|
| Hospital Charge Code |
11395
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.72 |
| Max. Negotiated Rate |
$15.63 |
| Rate for Payer: Aetna Commercial |
$14.07
|
| Rate for Payer: ASR ASR |
$15.16
|
| Rate for Payer: BCBS Trust/PPO |
$12.83
|
| Rate for Payer: BCN Commercial |
$12.83
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cofinity Commercial |
$14.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.50
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Healthscope Whirlpool |
$15.63
|
| Rate for Payer: Mclaren Commercial |
$14.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.28
|
| Rate for Payer: Nomi Health Commercial |
$12.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.75
|
|
|
SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA
|
Facility
|
OP
|
$40.33
|
|
|
Service Code
|
NDC 132020220
|
| Hospital Charge Code |
116987
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$40.33 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Aetna Medicare |
$14.92
|
| Rate for Payer: ASR ASR |
$39.12
|
| Rate for Payer: BCBS Complete |
$16.13
|
| Rate for Payer: BCBS Trust/PPO |
$33.25
|
| Rate for Payer: BCN Commercial |
$33.25
|
| Rate for Payer: Cash Price |
$32.26
|
| Rate for Payer: Cofinity Commercial |
$37.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.26
|
| Rate for Payer: Healthscope Commercial |
$39.12
|
| Rate for Payer: Healthscope Whirlpool |
$40.33
|
| Rate for Payer: Mclaren Commercial |
$36.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$32.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.28
|
| Rate for Payer: Nomi Health Commercial |
$33.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$30.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$35.33
|
| Rate for Payer: Priority Health Narrow Network |
$28.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$35.49
|
|
|
SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA
|
Facility
|
IP
|
$40.33
|
|
|
Service Code
|
NDC 132020220
|
| Hospital Charge Code |
116987
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.24 |
| Max. Negotiated Rate |
$40.33 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: ASR ASR |
$39.12
|
| Rate for Payer: BCBS Trust/PPO |
$33.12
|
| Rate for Payer: BCN Commercial |
$33.12
|
| Rate for Payer: Cash Price |
$32.26
|
| Rate for Payer: Cofinity Commercial |
$37.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.26
|
| Rate for Payer: Healthscope Commercial |
$39.12
|
| Rate for Payer: Healthscope Whirlpool |
$40.33
|
| Rate for Payer: Mclaren Commercial |
$36.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.28
|
| Rate for Payer: Nomi Health Commercial |
$33.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$30.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$35.49
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$351.45
|
|
|
Service Code
|
HCPCS J0209
|
| Hospital Charge Code |
7364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$351.45 |
| Rate for Payer: Aetna Commercial |
$316.31
|
| Rate for Payer: Aetna Medicare |
$0.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.10
|
| Rate for Payer: ASR ASR |
$340.91
|
| Rate for Payer: BCBS Complete |
$0.48
|
| Rate for Payer: BCBS MAPPO |
$0.88
|
| Rate for Payer: BCBS Trust/PPO |
$289.77
|
| Rate for Payer: BCN Commercial |
$289.77
|
| Rate for Payer: BCN Medicare Advantage |
$0.88
|
| Rate for Payer: Cash Price |
$281.16
|
| Rate for Payer: Cash Price |
$281.16
|
| Rate for Payer: Cofinity Commercial |
$330.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$281.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.88
|
| Rate for Payer: Healthscope Commercial |
$340.91
|
| Rate for Payer: Healthscope Whirlpool |
$351.45
|
| Rate for Payer: Humana Choice PPO Medicare |
$0.88
|
| Rate for Payer: Mclaren Commercial |
$316.31
|
| Rate for Payer: Mclaren Medicaid |
$0.88
|
| Rate for Payer: Mclaren Medicare |
$0.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.92
|
| Rate for Payer: Meridian Medicaid |
$0.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.01
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$298.73
|
| Rate for Payer: Nomi Health Commercial |
$288.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$263.59
|
| Rate for Payer: PACE Medicare |
$0.84
|
| Rate for Payer: PACE SWMI |
$0.88
|
| Rate for Payer: PHP Commercial |
$0.97
|
| Rate for Payer: PHP Medicaid |
$0.47
|
| Rate for Payer: PHP Medicare Advantage |
$0.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.82
|
| Rate for Payer: Priority Health Medicare |
$0.88
|
| Rate for Payer: Priority Health Narrow Network |
$0.66
|
| Rate for Payer: Railroad Medicare Medicare |
$0.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$309.28
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$0.88
|
| Rate for Payer: UHC Exchange |
$1.36
|
| Rate for Payer: UHC Medicaid |
$0.46
|
| Rate for Payer: UHCCP DNSP |
$0.88
|
| Rate for Payer: UHCCP Medicaid |
$0.46
|
| Rate for Payer: VA VA |
$0.88
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$351.45
|
|
|
Service Code
|
HCPCS J0209
|
| Hospital Charge Code |
7364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$263.59 |
| Max. Negotiated Rate |
$351.45 |
| Rate for Payer: Aetna Commercial |
$316.31
|
| Rate for Payer: ASR ASR |
$340.91
|
| Rate for Payer: BCBS Trust/PPO |
$288.61
|
| Rate for Payer: BCN Commercial |
$288.61
|
| Rate for Payer: Cash Price |
$281.16
|
| Rate for Payer: Cofinity Commercial |
$330.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$281.16
|
| Rate for Payer: Healthscope Commercial |
$340.91
|
| Rate for Payer: Healthscope Whirlpool |
$351.45
|
| Rate for Payer: Mclaren Commercial |
$316.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$298.73
|
| Rate for Payer: Nomi Health Commercial |
$288.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$263.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$309.28
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$80.41
|
|
|
Service Code
|
NDC 310111001
|
| Hospital Charge Code |
188049
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.31 |
| Max. Negotiated Rate |
$80.41 |
| Rate for Payer: Aetna Commercial |
$72.37
|
| Rate for Payer: ASR ASR |
$78.00
|
| Rate for Payer: BCBS Trust/PPO |
$66.03
|
| Rate for Payer: BCN Commercial |
$66.03
|
| Rate for Payer: Cash Price |
$64.33
|
| Rate for Payer: Cofinity Commercial |
$75.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.33
|
| Rate for Payer: Healthscope Commercial |
$78.00
|
| Rate for Payer: Healthscope Whirlpool |
$80.41
|
| Rate for Payer: Mclaren Commercial |
$72.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.35
|
| Rate for Payer: Nomi Health Commercial |
$65.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$60.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.76
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$884.45
|
|
|
Service Code
|
NDC 310111039
|
| Hospital Charge Code |
188049
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$663.34 |
| Max. Negotiated Rate |
$884.45 |
| Rate for Payer: Aetna Commercial |
$796.01
|
| Rate for Payer: ASR ASR |
$857.92
|
| Rate for Payer: BCBS Trust/PPO |
$726.31
|
| Rate for Payer: BCN Commercial |
$726.31
|
| Rate for Payer: Cash Price |
$707.56
|
| Rate for Payer: Cofinity Commercial |
$831.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$707.56
|
| Rate for Payer: Healthscope Commercial |
$857.92
|
| Rate for Payer: Healthscope Whirlpool |
$884.45
|
| Rate for Payer: Mclaren Commercial |
$796.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$751.78
|
| Rate for Payer: Nomi Health Commercial |
$725.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$663.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$778.32
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$884.45
|
|
|
Service Code
|
NDC 310111039
|
| Hospital Charge Code |
188049
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$327.25 |
| Max. Negotiated Rate |
$884.45 |
| Rate for Payer: Aetna Commercial |
$796.01
|
| Rate for Payer: Aetna Medicare |
$327.25
|
| Rate for Payer: ASR ASR |
$857.92
|
| Rate for Payer: BCBS Complete |
$353.78
|
| Rate for Payer: BCBS Trust/PPO |
$729.23
|
| Rate for Payer: BCN Commercial |
$729.23
|
| Rate for Payer: Cash Price |
$707.56
|
| Rate for Payer: Cofinity Commercial |
$831.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$707.56
|
| Rate for Payer: Healthscope Commercial |
$857.92
|
| Rate for Payer: Healthscope Whirlpool |
$884.45
|
| Rate for Payer: Mclaren Commercial |
$796.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$707.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$751.78
|
| Rate for Payer: Nomi Health Commercial |
$725.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$663.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$774.96
|
| Rate for Payer: Priority Health Narrow Network |
$620.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$778.32
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$80.41
|
|
|
Service Code
|
NDC 310111001
|
| Hospital Charge Code |
188049
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$80.41 |
| Rate for Payer: Aetna Commercial |
$72.37
|
| Rate for Payer: Aetna Medicare |
$29.75
|
| Rate for Payer: ASR ASR |
$78.00
|
| Rate for Payer: BCBS Complete |
$32.16
|
| Rate for Payer: BCBS Trust/PPO |
$66.30
|
| Rate for Payer: BCN Commercial |
$66.30
|
| Rate for Payer: Cash Price |
$64.33
|
| Rate for Payer: Cofinity Commercial |
$75.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.33
|
| Rate for Payer: Healthscope Commercial |
$78.00
|
| Rate for Payer: Healthscope Whirlpool |
$80.41
|
| Rate for Payer: Mclaren Commercial |
$72.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$64.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.35
|
| Rate for Payer: Nomi Health Commercial |
$65.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$60.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$70.45
|
| Rate for Payer: Priority Health Narrow Network |
$56.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.76
|
|
|
SOFT TISSUE PROCEDURES WITH CC
|
Facility
|
IP
|
$24,016.80
|
|
|
Service Code
|
MSDRG 501
|
| Min. Negotiated Rate |
$13,625.81 |
| Max. Negotiated Rate |
$24,016.80 |
| Rate for Payer: Aetna Medicare |
$14,342.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,928.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,928.70
|
| Rate for Payer: BCBS MAPPO |
$14,342.96
|
| Rate for Payer: BCN Medicare Advantage |
$14,342.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,342.96
|
| Rate for Payer: Humana Choice PPO Medicare |
$14,342.96
|
| Rate for Payer: Mclaren Medicare |
$14,342.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15,060.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,494.40
|
| Rate for Payer: Molina Medicare/Medicaid |
$15,777.26
|
| Rate for Payer: PACE Medicare |
$13,625.81
|
| Rate for Payer: PACE SWMI |
$14,342.96
|
| Rate for Payer: PHP Commercial |
$15,777.26
|
| Rate for Payer: PHP Medicare Advantage |
$14,342.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$24,016.80
|
| Rate for Payer: Priority Health Medicare |
$14,342.96
|
| Rate for Payer: Priority Health Narrow Network |
$19,213.44
|
| Rate for Payer: Railroad Medicare Medicare |
$14,342.96
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$14,342.96
|
| Rate for Payer: UHC Exchange |
$22,231.59
|
| Rate for Payer: UHCCP DNSP |
$14,342.96
|
| Rate for Payer: VA VA |
$14,342.96
|
|
|
SOFT TISSUE PROCEDURES WITH MCC
|
Facility
|
IP
|
$43,480.55
|
|
|
Service Code
|
MSDRG 500
|
| Min. Negotiated Rate |
$23,317.71 |
| Max. Negotiated Rate |
$43,480.55 |
| Rate for Payer: Aetna Medicare |
$24,544.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30,681.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30,681.20
|
| Rate for Payer: BCBS MAPPO |
$24,544.96
|
| Rate for Payer: BCN Medicare Advantage |
$24,544.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24,544.96
|
| Rate for Payer: Humana Choice PPO Medicare |
$24,544.96
|
| Rate for Payer: Mclaren Medicare |
$24,544.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25,772.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28,226.70
|
| Rate for Payer: Molina Medicare/Medicaid |
$26,999.46
|
| Rate for Payer: PACE Medicare |
$23,317.71
|
| Rate for Payer: PACE SWMI |
$24,544.96
|
| Rate for Payer: PHP Commercial |
$26,999.46
|
| Rate for Payer: PHP Medicare Advantage |
$24,544.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$43,480.55
|
| Rate for Payer: Priority Health Medicare |
$24,544.96
|
| Rate for Payer: Priority Health Narrow Network |
$34,784.44
|
| Rate for Payer: Railroad Medicare Medicare |
$24,544.96
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$24,544.96
|
| Rate for Payer: UHC Exchange |
$38,044.69
|
| Rate for Payer: UHCCP DNSP |
$24,544.96
|
| Rate for Payer: VA VA |
$24,544.96
|
|
|
SOFT TISSUE PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$18,491.05
|
|
|
Service Code
|
MSDRG 502
|
| Min. Negotiated Rate |
$10,874.29 |
| Max. Negotiated Rate |
$18,491.05 |
| Rate for Payer: Aetna Medicare |
$11,446.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,308.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,308.27
|
| Rate for Payer: BCBS MAPPO |
$11,446.62
|
| Rate for Payer: BCN Medicare Advantage |
$11,446.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,446.62
|
| Rate for Payer: Humana Choice PPO Medicare |
$11,446.62
|
| Rate for Payer: Mclaren Medicare |
$11,446.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,018.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,163.61
|
| Rate for Payer: Molina Medicare/Medicaid |
$12,591.28
|
| Rate for Payer: PACE Medicare |
$10,874.29
|
| Rate for Payer: PACE SWMI |
$11,446.62
|
| Rate for Payer: PHP Commercial |
$12,591.28
|
| Rate for Payer: PHP Medicare Advantage |
$11,446.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18,491.05
|
| Rate for Payer: Priority Health Medicare |
$11,446.62
|
| Rate for Payer: Priority Health Narrow Network |
$14,792.84
|
| Rate for Payer: Railroad Medicare Medicare |
$11,446.62
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$11,446.62
|
| Rate for Payer: UHC Exchange |
$17,742.26
|
| Rate for Payer: UHCCP DNSP |
$11,446.62
|
| Rate for Payer: VA VA |
$11,446.62
|
|
|
SOTALOL 80 MG TABLET
|
Facility
|
IP
|
$143.35
|
|
|
Service Code
|
NDC 60505008000
|
| Hospital Charge Code |
11421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.51 |
| Max. Negotiated Rate |
$143.35 |
| Rate for Payer: Aetna Commercial |
$129.01
|
| Rate for Payer: ASR ASR |
$139.05
|
| Rate for Payer: BCBS Trust/PPO |
$117.72
|
| Rate for Payer: BCN Commercial |
$117.72
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$134.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$139.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.35
|
| Rate for Payer: Mclaren Commercial |
$129.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Nomi Health Commercial |
$117.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$126.15
|
|
|
SOTALOL 80 MG TABLET
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 245001289
|
| Hospital Charge Code |
11421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Aetna Medicare |
$1.64
|
| Rate for Payer: ASR ASR |
$4.31
|
| Rate for Payer: BCBS Complete |
$1.78
|
| Rate for Payer: BCBS Trust/PPO |
$3.66
|
| Rate for Payer: BCN Commercial |
$3.66
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Cofinity Commercial |
$4.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.55
|
| Rate for Payer: Healthscope Commercial |
$4.31
|
| Rate for Payer: Healthscope Whirlpool |
$4.44
|
| Rate for Payer: Mclaren Commercial |
$4.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.77
|
| Rate for Payer: Nomi Health Commercial |
$3.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.89
|
| Rate for Payer: Priority Health Narrow Network |
$3.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.91
|
|
