|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$15.07
|
|
|
Service Code
|
NDC 67877012425
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$15.07 |
| Rate for Payer: Aetna Commercial |
$13.56
|
| Rate for Payer: ASR ASR |
$14.62
|
| Rate for Payer: ASR Commercial |
$14.62
|
| Rate for Payer: BCBS Trust/PPO |
$12.28
|
| Rate for Payer: BCN Commercial |
$11.68
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.07
|
| Rate for Payer: Healthscope Whirlpool |
$14.62
|
| Rate for Payer: Mclaren Commercial |
$13.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.81
|
| Rate for Payer: Nomi Health Commercial |
$12.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.26
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
NDC 77333081225
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Aetna Medicare |
$1.75
|
| Rate for Payer: ASR ASR |
$3.40
|
| Rate for Payer: ASR Commercial |
$3.40
|
| Rate for Payer: BCBS Complete |
$1.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.87
|
| Rate for Payer: BCN Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.50
|
| Rate for Payer: Healthscope Whirlpool |
$3.40
|
| Rate for Payer: Mclaren Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.07
|
| Rate for Payer: Priority Health Narrow Network |
$2.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.08
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$54.05
|
|
|
Service Code
|
NDC 00904720660
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.13 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna Commercial |
$48.65
|
| Rate for Payer: ASR ASR |
$52.43
|
| Rate for Payer: ASR Commercial |
$52.43
|
| Rate for Payer: BCBS Trust/PPO |
$44.05
|
| Rate for Payer: BCN Commercial |
$41.90
|
| Rate for Payer: Cash Price |
$43.24
|
| Rate for Payer: Cofinity Commercial |
$50.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.24
|
| Rate for Payer: Healthscope Commercial |
$54.05
|
| Rate for Payer: Healthscope Whirlpool |
$52.43
|
| Rate for Payer: Mclaren Commercial |
$48.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.94
|
| Rate for Payer: Nomi Health Commercial |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.56
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
NDC 77333081225
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: ASR ASR |
$3.40
|
| Rate for Payer: ASR Commercial |
$3.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.85
|
| Rate for Payer: BCN Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.50
|
| Rate for Payer: Healthscope Whirlpool |
$3.40
|
| Rate for Payer: Mclaren Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.08
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$350.15
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.06 |
| Max. Negotiated Rate |
$350.15 |
| Rate for Payer: Aetna Commercial |
$315.13
|
| Rate for Payer: Aetna Medicare |
$175.07
|
| Rate for Payer: ASR ASR |
$339.65
|
| Rate for Payer: ASR Commercial |
$339.65
|
| Rate for Payer: BCBS Complete |
$140.06
|
| Rate for Payer: BCBS Trust/PPO |
$286.74
|
| Rate for Payer: BCN Commercial |
$271.47
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$329.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$350.15
|
| Rate for Payer: Healthscope Whirlpool |
$339.65
|
| Rate for Payer: Mclaren Commercial |
$315.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: Nomi Health Commercial |
$287.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$306.80
|
| Rate for Payer: Priority Health Narrow Network |
$245.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.13
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$227.60 |
| Max. Negotiated Rate |
$350.15 |
| Rate for Payer: Aetna Commercial |
$315.13
|
| Rate for Payer: ASR ASR |
$339.65
|
| Rate for Payer: ASR Commercial |
$339.65
|
| Rate for Payer: BCBS Trust/PPO |
$285.34
|
| Rate for Payer: BCN Commercial |
$271.47
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$329.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$350.15
|
| Rate for Payer: Healthscope Whirlpool |
$339.65
|
| Rate for Payer: Mclaren Commercial |
$315.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.63
|
| Rate for Payer: Nomi Health Commercial |
$287.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.13
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
OP
|
$54.05
|
|
|
Service Code
|
NDC 00904720660
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.62 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna Commercial |
$48.65
|
| Rate for Payer: Aetna Medicare |
$27.02
|
| Rate for Payer: ASR ASR |
$52.43
|
| Rate for Payer: ASR Commercial |
$52.43
|
| Rate for Payer: BCBS Complete |
$21.62
|
| Rate for Payer: BCBS Trust/PPO |
$44.26
|
| Rate for Payer: BCN Commercial |
$41.90
|
| Rate for Payer: Cash Price |
$43.24
|
| Rate for Payer: Cofinity Commercial |
$50.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.24
|
| Rate for Payer: Healthscope Commercial |
$54.05
|
| Rate for Payer: Healthscope Whirlpool |
$52.43
|
| Rate for Payer: Mclaren Commercial |
$48.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.94
|
| Rate for Payer: Nomi Health Commercial |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$47.36
|
| Rate for Payer: Priority Health Narrow Network |
$37.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.56
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM
|
Facility
|
OP
|
$603.96
|
|
|
Service Code
|
CPT 12016
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$208.85 |
| Max. Negotiated Rate |
$603.96 |
| Rate for Payer: Aetna Medicare |
$389.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$487.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$487.06
|
| Rate for Payer: BCBS Complete |
$219.30
|
| Rate for Payer: BCBS MAPPO |
$389.65
|
| Rate for Payer: BCN Medicare Advantage |
$389.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$389.65
|
| Rate for Payer: Humana Choice PPO Medicare |
$389.65
|
| Rate for Payer: Mclaren Medicaid |
$208.85
|
| Rate for Payer: Mclaren Medicare |
$389.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$409.13
|
| Rate for Payer: Meridian Medicaid |
$219.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$448.10
|
| Rate for Payer: PACE Medicare |
$370.17
|
| Rate for Payer: PACE SWMI |
$389.65
|
| Rate for Payer: PHP Commercial |
$428.62
|
| Rate for Payer: PHP Medicaid |
$208.85
|
| Rate for Payer: PHP Medicare Advantage |
$389.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$208.85
|
| Rate for Payer: Priority Health Medicare |
$389.65
|
| Rate for Payer: Railroad Medicare Medicare |
$389.65
|
| Rate for Payer: UHC Dual Complete DSNP |
$389.65
|
| Rate for Payer: UHC Exchange |
$603.96
|
| Rate for Payer: UHC Medicare Advantage |
$389.65
|
| Rate for Payer: UHCCP DNSP |
$389.65
|
| Rate for Payer: UHCCP Medicaid |
$208.85
|
| Rate for Payer: VA VA |
$389.65
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS
|
Facility
|
OP
|
$300.37
|
|
|
Service Code
|
CPT 12001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$103.87 |
| Max. Negotiated Rate |
$300.37 |
| Rate for Payer: Aetna Medicare |
$193.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$242.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$242.24
|
| Rate for Payer: BCBS Complete |
$109.07
|
| Rate for Payer: BCBS MAPPO |
$193.79
|
| Rate for Payer: BCN Medicare Advantage |
$193.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$193.79
|
| Rate for Payer: Humana Choice PPO Medicare |
$193.79
|
| Rate for Payer: Mclaren Medicaid |
$103.87
|
| Rate for Payer: Mclaren Medicare |
$193.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$203.48
|
| Rate for Payer: Meridian Medicaid |
$109.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$222.86
|
| Rate for Payer: PACE Medicare |
$184.10
|
| Rate for Payer: PACE SWMI |
$193.79
|
| Rate for Payer: PHP Commercial |
$213.17
|
| Rate for Payer: PHP Medicaid |
$103.87
|
| Rate for Payer: PHP Medicare Advantage |
$193.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$103.87
|
| Rate for Payer: Priority Health Medicare |
$193.79
|
| Rate for Payer: Railroad Medicare Medicare |
$193.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$193.79
|
| Rate for Payer: UHC Exchange |
$300.37
|
| Rate for Payer: UHC Medicare Advantage |
$193.79
|
| Rate for Payer: UHCCP DNSP |
$193.79
|
| Rate for Payer: UHCCP Medicaid |
$103.87
|
| Rate for Payer: VA VA |
$193.79
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM
|
Facility
|
OP
|
$300.37
|
|
|
Service Code
|
CPT 12002
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$103.87 |
| Max. Negotiated Rate |
$300.37 |
| Rate for Payer: Aetna Medicare |
$193.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$242.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$242.24
|
| Rate for Payer: BCBS Complete |
$109.07
|
| Rate for Payer: BCBS MAPPO |
$193.79
|
| Rate for Payer: BCN Medicare Advantage |
$193.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$193.79
|
| Rate for Payer: Humana Choice PPO Medicare |
$193.79
|
| Rate for Payer: Mclaren Medicaid |
$103.87
|
| Rate for Payer: Mclaren Medicare |
$193.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$203.48
|
| Rate for Payer: Meridian Medicaid |
$109.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$222.86
|
| Rate for Payer: PACE Medicare |
$184.10
|
| Rate for Payer: PACE SWMI |
$193.79
|
| Rate for Payer: PHP Commercial |
$213.17
|
| Rate for Payer: PHP Medicaid |
$103.87
|
| Rate for Payer: PHP Medicare Advantage |
$193.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$103.87
|
| Rate for Payer: Priority Health Medicare |
$193.79
|
| Rate for Payer: Railroad Medicare Medicare |
$193.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$193.79
|
| Rate for Payer: UHC Exchange |
$300.37
|
| Rate for Payer: UHC Medicare Advantage |
$193.79
|
| Rate for Payer: UHCCP DNSP |
$193.79
|
| Rate for Payer: UHCCP Medicaid |
$103.87
|
| Rate for Payer: VA VA |
$193.79
|
|
|
SIMVASTATIN 10 MG TABLET
|
Facility
|
OP
|
$253.80
|
|
|
Service Code
|
NDC 63739057110
|
| Hospital Charge Code |
11364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.52 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna Commercial |
$228.42
|
| Rate for Payer: Aetna Medicare |
$126.90
|
| Rate for Payer: ASR ASR |
$246.19
|
| Rate for Payer: ASR Commercial |
$246.19
|
| Rate for Payer: BCBS Complete |
$101.52
|
| Rate for Payer: BCBS Trust/PPO |
$207.84
|
| Rate for Payer: BCN Commercial |
$196.77
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$238.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Healthscope Whirlpool |
$246.19
|
| Rate for Payer: Mclaren Commercial |
$228.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: Nomi Health Commercial |
$208.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$222.38
|
| Rate for Payer: Priority Health Narrow Network |
$177.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.34
|
|
|
SIMVASTATIN 10 MG TABLET
|
Facility
|
IP
|
$253.80
|
|
|
Service Code
|
NDC 63739057110
|
| Hospital Charge Code |
11364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.97 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna Commercial |
$228.42
|
| Rate for Payer: ASR ASR |
$246.19
|
| Rate for Payer: ASR Commercial |
$246.19
|
| Rate for Payer: BCBS Trust/PPO |
$206.82
|
| Rate for Payer: BCN Commercial |
$196.77
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$238.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Healthscope Whirlpool |
$246.19
|
| Rate for Payer: Mclaren Commercial |
$228.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: Nomi Health Commercial |
$208.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.34
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET
|
Facility
|
OP
|
$1,135.31
|
|
|
Service Code
|
NDC 00006027731
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$454.12 |
| Max. Negotiated Rate |
$1,135.31 |
| Rate for Payer: Aetna Commercial |
$1,021.78
|
| Rate for Payer: Aetna Medicare |
$567.65
|
| Rate for Payer: ASR ASR |
$1,101.25
|
| Rate for Payer: ASR Commercial |
$1,101.25
|
| Rate for Payer: BCBS Complete |
$454.12
|
| Rate for Payer: BCBS Trust/PPO |
$929.71
|
| Rate for Payer: BCN Commercial |
$880.21
|
| Rate for Payer: Cash Price |
$908.25
|
| Rate for Payer: Cofinity Commercial |
$1,067.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$908.25
|
| Rate for Payer: Healthscope Commercial |
$1,135.31
|
| Rate for Payer: Healthscope Whirlpool |
$1,101.25
|
| Rate for Payer: Mclaren Commercial |
$1,021.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$965.01
|
| Rate for Payer: Nomi Health Commercial |
$930.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$737.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$994.76
|
| Rate for Payer: Priority Health Narrow Network |
$795.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$999.07
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET
|
Facility
|
IP
|
$1,135.31
|
|
|
Service Code
|
NDC 00006027731
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$737.95 |
| Max. Negotiated Rate |
$1,135.31 |
| Rate for Payer: Aetna Commercial |
$1,021.78
|
| Rate for Payer: ASR ASR |
$1,101.25
|
| Rate for Payer: ASR Commercial |
$1,101.25
|
| Rate for Payer: BCBS Trust/PPO |
$925.16
|
| Rate for Payer: BCN Commercial |
$880.21
|
| Rate for Payer: Cash Price |
$908.25
|
| Rate for Payer: Cofinity Commercial |
$1,067.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$908.25
|
| Rate for Payer: Healthscope Commercial |
$1,135.31
|
| Rate for Payer: Healthscope Whirlpool |
$1,101.25
|
| Rate for Payer: Mclaren Commercial |
$1,021.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$965.01
|
| Rate for Payer: Nomi Health Commercial |
$930.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$737.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$999.07
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET
|
Facility
|
OP
|
$3,406.26
|
|
|
Service Code
|
NDC 00006022154
|
| Hospital Charge Code |
77615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,362.50 |
| Max. Negotiated Rate |
$3,406.26 |
| Rate for Payer: Aetna Commercial |
$3,065.63
|
| Rate for Payer: Aetna Medicare |
$1,703.13
|
| Rate for Payer: ASR ASR |
$3,304.07
|
| Rate for Payer: ASR Commercial |
$3,304.07
|
| Rate for Payer: BCBS Complete |
$1,362.50
|
| Rate for Payer: BCBS Trust/PPO |
$2,789.39
|
| Rate for Payer: BCN Commercial |
$2,640.87
|
| Rate for Payer: Cash Price |
$2,725.01
|
| Rate for Payer: Cofinity Commercial |
$3,201.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,725.01
|
| Rate for Payer: Healthscope Commercial |
$3,406.26
|
| Rate for Payer: Healthscope Whirlpool |
$3,304.07
|
| Rate for Payer: Mclaren Commercial |
$3,065.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,895.32
|
| Rate for Payer: Nomi Health Commercial |
$2,793.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,214.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,984.57
|
| Rate for Payer: Priority Health Narrow Network |
$2,387.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,997.51
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET
|
Facility
|
IP
|
$3,406.26
|
|
|
Service Code
|
NDC 00006022154
|
| Hospital Charge Code |
77615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,214.07 |
| Max. Negotiated Rate |
$3,406.26 |
| Rate for Payer: Aetna Commercial |
$3,065.63
|
| Rate for Payer: ASR ASR |
$3,304.07
|
| Rate for Payer: ASR Commercial |
$3,304.07
|
| Rate for Payer: BCBS Trust/PPO |
$2,775.76
|
| Rate for Payer: BCN Commercial |
$2,640.87
|
| Rate for Payer: Cash Price |
$2,725.01
|
| Rate for Payer: Cofinity Commercial |
$3,201.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,725.01
|
| Rate for Payer: Healthscope Commercial |
$3,406.26
|
| Rate for Payer: Healthscope Whirlpool |
$3,304.07
|
| Rate for Payer: Mclaren Commercial |
$3,065.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,895.32
|
| Rate for Payer: Nomi Health Commercial |
$2,793.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,214.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,997.51
|
|
|
SKIN CARE CONSULT
|
Professional
|
Both
|
$26.00
|
|
|
Service Code
|
HCPCS 00177
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Aetna Medicare |
$13.00
|
| Rate for Payer: BCBS Complete |
$10.40
|
| Rate for Payer: Cash Price |
$20.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.90
|
|
|
SOAP BAR
|
Facility
|
IP
|
$12.55
|
|
|
Service Code
|
NDC 70501001010
|
| Hospital Charge Code |
108564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$12.55 |
| Rate for Payer: Aetna Commercial |
$11.29
|
| Rate for Payer: ASR ASR |
$12.17
|
| Rate for Payer: ASR Commercial |
$12.17
|
| Rate for Payer: BCBS Trust/PPO |
$10.23
|
| Rate for Payer: BCN Commercial |
$9.73
|
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: Cofinity Commercial |
$11.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.04
|
| Rate for Payer: Healthscope Commercial |
$12.55
|
| Rate for Payer: Healthscope Whirlpool |
$12.17
|
| Rate for Payer: Mclaren Commercial |
$11.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.67
|
| Rate for Payer: Nomi Health Commercial |
$10.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.04
|
|
|
SOAP BAR
|
Facility
|
OP
|
$12.55
|
|
|
Service Code
|
NDC 70501001010
|
| Hospital Charge Code |
108564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.02 |
| Max. Negotiated Rate |
$12.55 |
| Rate for Payer: Aetna Commercial |
$11.29
|
| Rate for Payer: Aetna Medicare |
$6.28
|
| Rate for Payer: ASR ASR |
$12.17
|
| Rate for Payer: ASR Commercial |
$12.17
|
| Rate for Payer: BCBS Complete |
$5.02
|
| Rate for Payer: BCBS Trust/PPO |
$10.28
|
| Rate for Payer: BCN Commercial |
$9.73
|
| Rate for Payer: Cash Price |
$10.04
|
| Rate for Payer: Cofinity Commercial |
$11.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.04
|
| Rate for Payer: Healthscope Commercial |
$12.55
|
| Rate for Payer: Healthscope Whirlpool |
$12.17
|
| Rate for Payer: Mclaren Commercial |
$11.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.67
|
| Rate for Payer: Nomi Health Commercial |
$10.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.00
|
| Rate for Payer: Priority Health Narrow Network |
$8.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.04
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$35.60
|
|
|
Service Code
|
NDC 00409662530
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.24 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: Aetna Medicare |
$17.80
|
| Rate for Payer: ASR ASR |
$34.53
|
| Rate for Payer: ASR Commercial |
$34.53
|
| Rate for Payer: BCBS Complete |
$14.24
|
| Rate for Payer: BCBS Trust/PPO |
$29.15
|
| 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 Commercial |
$30.26
|
| Rate for Payer: Nomi Health Commercial |
$29.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31.19
|
| Rate for Payer: Priority Health Narrow Network |
$24.96
|
| 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 51754500105
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$36.05 |
| Rate for Payer: Aetna Commercial |
$32.45
|
| Rate for Payer: ASR ASR |
$34.97
|
| Rate for Payer: ASR Commercial |
$34.97
|
| Rate for Payer: BCBS Trust/PPO |
$29.38
|
| 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 |
$32.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.64
|
| Rate for Payer: Nomi Health Commercial |
$29.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.72
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$43.39
|
|
|
Service Code
|
NDC 81298762003
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$43.39 |
| Rate for Payer: Aetna Commercial |
$39.05
|
| Rate for Payer: ASR ASR |
$42.09
|
| Rate for Payer: ASR Commercial |
$42.09
|
| Rate for Payer: BCBS Trust/PPO |
$35.36
|
| Rate for Payer: BCN Commercial |
$33.64
|
| Rate for Payer: Cash Price |
$34.71
|
| Rate for Payer: Cofinity Commercial |
$40.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.71
|
| Rate for Payer: Healthscope Commercial |
$43.39
|
| Rate for Payer: Healthscope Whirlpool |
$42.09
|
| Rate for Payer: Mclaren Commercial |
$39.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.88
|
| Rate for Payer: Nomi Health Commercial |
$35.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$38.18
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$43.39
|
|
|
Service Code
|
NDC 81298762001
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$43.39 |
| Rate for Payer: Aetna Commercial |
$39.05
|
| Rate for Payer: Aetna Medicare |
$21.70
|
| Rate for Payer: ASR ASR |
$42.09
|
| Rate for Payer: ASR Commercial |
$42.09
|
| Rate for Payer: BCBS Complete |
$17.36
|
| Rate for Payer: BCBS Trust/PPO |
$35.53
|
| Rate for Payer: BCN Commercial |
$33.64
|
| Rate for Payer: Cash Price |
$34.71
|
| Rate for Payer: Cofinity Commercial |
$40.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.71
|
| Rate for Payer: Healthscope Commercial |
$43.39
|
| Rate for Payer: Healthscope Whirlpool |
$42.09
|
| Rate for Payer: Mclaren Commercial |
$39.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.88
|
| Rate for Payer: Nomi Health Commercial |
$35.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38.02
|
| Rate for Payer: Priority Health Narrow Network |
$30.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$38.18
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$35.60
|
|
|
Service Code
|
NDC 00409662535
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.24 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: Aetna Medicare |
$17.80
|
| Rate for Payer: ASR ASR |
$34.53
|
| Rate for Payer: ASR Commercial |
$34.53
|
| Rate for Payer: BCBS Complete |
$14.24
|
| Rate for Payer: BCBS Trust/PPO |
$29.15
|
| 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 Commercial |
$30.26
|
| Rate for Payer: Nomi Health Commercial |
$29.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31.19
|
| Rate for Payer: Priority Health Narrow Network |
$24.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.33
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$36.05
|
|
|
Service Code
|
NDC 51754500105
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$36.05 |
| Rate for Payer: Aetna Commercial |
$32.45
|
| Rate for Payer: Aetna Medicare |
$18.02
|
| Rate for Payer: ASR ASR |
$34.97
|
| Rate for Payer: ASR Commercial |
$34.97
|
| Rate for Payer: BCBS Complete |
$14.42
|
| Rate for Payer: BCBS Trust/PPO |
$29.52
|
| 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 |
$32.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.64
|
| Rate for Payer: Nomi Health Commercial |
$29.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31.59
|
| Rate for Payer: Priority Health Narrow Network |
$25.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.72
|
|
