|
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
|
$301.75
|
|
|
Service Code
|
CPT 12001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$104.35 |
| Max. Negotiated Rate |
$301.75 |
| Rate for Payer: Aetna Medicare |
$194.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$243.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$243.35
|
| Rate for Payer: BCBS Complete |
$109.57
|
| Rate for Payer: BCBS MAPPO |
$194.68
|
| Rate for Payer: BCN Medicare Advantage |
$194.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$194.68
|
| Rate for Payer: Humana Choice PPO Medicare |
$194.68
|
| Rate for Payer: Mclaren Medicaid |
$104.35
|
| Rate for Payer: Mclaren Medicare |
$194.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$204.41
|
| Rate for Payer: Meridian Medicaid |
$109.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$223.88
|
| Rate for Payer: PACE Medicare |
$184.95
|
| Rate for Payer: PACE SWMI |
$194.68
|
| Rate for Payer: PHP Commercial |
$214.15
|
| Rate for Payer: PHP Medicaid |
$104.35
|
| Rate for Payer: PHP Medicare Advantage |
$194.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$265.98
|
| Rate for Payer: Priority Health Medicare |
$194.68
|
| Rate for Payer: Priority Health Narrow Network |
$212.78
|
| Rate for Payer: Railroad Medicare Medicare |
$194.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$194.68
|
| Rate for Payer: UHC Exchange |
$301.75
|
| Rate for Payer: UHC Medicare Advantage |
$194.68
|
| Rate for Payer: UHCCP DNSP |
$194.68
|
| Rate for Payer: UHCCP Medicaid |
$104.35
|
| Rate for Payer: VA VA |
$194.68
|
|
|
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
|
$301.75
|
|
|
Service Code
|
CPT 12002
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$104.35 |
| Max. Negotiated Rate |
$301.75 |
| Rate for Payer: Aetna Medicare |
$194.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$243.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$243.35
|
| Rate for Payer: BCBS Complete |
$109.57
|
| Rate for Payer: BCBS MAPPO |
$194.68
|
| Rate for Payer: BCN Medicare Advantage |
$194.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$194.68
|
| Rate for Payer: Humana Choice PPO Medicare |
$194.68
|
| Rate for Payer: Mclaren Medicaid |
$104.35
|
| Rate for Payer: Mclaren Medicare |
$194.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$204.41
|
| Rate for Payer: Meridian Medicaid |
$109.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$223.88
|
| Rate for Payer: PACE Medicare |
$184.95
|
| Rate for Payer: PACE SWMI |
$194.68
|
| Rate for Payer: PHP Commercial |
$214.15
|
| Rate for Payer: PHP Medicaid |
$104.35
|
| Rate for Payer: PHP Medicare Advantage |
$194.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$104.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$265.98
|
| Rate for Payer: Priority Health Medicare |
$194.68
|
| Rate for Payer: Priority Health Narrow Network |
$212.78
|
| Rate for Payer: Railroad Medicare Medicare |
$194.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$194.68
|
| Rate for Payer: UHC Exchange |
$301.75
|
| Rate for Payer: UHC Medicare Advantage |
$194.68
|
| Rate for Payer: UHCCP DNSP |
$194.68
|
| Rate for Payer: UHCCP Medicaid |
$104.35
|
| Rate for Payer: VA VA |
$194.68
|
|
|
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
|
|
|
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
|
|
|
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 |
$567.66
|
| 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
|
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
|
|
|
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
|
|
|
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
|
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 |
$11.30
|
| 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 |
$11.30
|
| 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
|
|
|
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 |
$11.30
|
| 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 |
$11.30
|
| 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
|
|
|
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
|
$43.39
|
|
|
Service Code
|
NDC 81298762003
|
| 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
|
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
|
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 |
$32.44
|
| 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 |
$32.44
|
| 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
|
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 |
$32.44
|
| 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 |
$32.44
|
| 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
|
|
|
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
|
$38.94
|
|
|
Service Code
|
NDC 51754500101
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.31 |
| Max. Negotiated Rate |
$38.94 |
| Rate for Payer: Aetna Commercial |
$35.05
|
| Rate for Payer: ASR ASR |
$37.77
|
| Rate for Payer: ASR Commercial |
$37.77
|
| Rate for Payer: BCBS Trust/PPO |
$31.73
|
| Rate for Payer: BCN Commercial |
$30.19
|
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: Cofinity Commercial |
$36.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.15
|
| Rate for Payer: Healthscope Commercial |
$38.94
|
| Rate for Payer: Healthscope Whirlpool |
$37.77
|
| Rate for Payer: Mclaren Commercial |
$35.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.10
|
| Rate for Payer: Nomi Health Commercial |
$31.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$34.27
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$38.94
|
|
|
Service Code
|
NDC 51754500101
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.58 |
| Max. Negotiated Rate |
$38.94 |
| Rate for Payer: Aetna Commercial |
$35.05
|
| Rate for Payer: Aetna Medicare |
$19.47
|
| Rate for Payer: ASR ASR |
$37.77
|
| Rate for Payer: ASR Commercial |
$37.77
|
| Rate for Payer: BCBS Complete |
$15.58
|
| Rate for Payer: BCBS Trust/PPO |
$31.89
|
| Rate for Payer: BCN Commercial |
$30.19
|
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: Cofinity Commercial |
$36.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.15
|
| Rate for Payer: Healthscope Commercial |
$38.94
|
| Rate for Payer: Healthscope Whirlpool |
$37.77
|
| Rate for Payer: Mclaren Commercial |
$35.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.10
|
| Rate for Payer: Nomi Health Commercial |
$31.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34.12
|
| Rate for Payer: Priority Health Narrow Network |
$27.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$34.27
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$35.60
|
|
|
Service Code
|
NDC 00409662530
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.14 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: ASR ASR |
$34.53
|
| Rate for Payer: ASR Commercial |
$34.53
|
| Rate for Payer: BCBS Trust/PPO |
$29.01
|
| 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: UHC All Payor (Choice/PPO) + Core |
$31.33
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$35.60
|
|
|
Service Code
|
NDC 00409662535
|
| Hospital Charge Code |
108819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.14 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: ASR ASR |
$34.53
|
| Rate for Payer: ASR Commercial |
$34.53
|
| Rate for Payer: BCBS Trust/PPO |
$29.01
|
| 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: UHC All Payor (Choice/PPO) + Core |
$31.33
|
|
|
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
|
IP
|
$43.39
|
|
|
Service Code
|
NDC 81298762001
|
| 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 650 MG TABLET
|
Facility
|
OP
|
$159.80
|
|
|
Service Code
|
NDC 00223172101
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.92 |
| Max. Negotiated Rate |
$159.80 |
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: Aetna Medicare |
$79.90
|
| Rate for Payer: ASR ASR |
$155.01
|
| Rate for Payer: ASR Commercial |
$155.01
|
| Rate for Payer: BCBS Complete |
$63.92
|
| Rate for Payer: BCBS Trust/PPO |
$130.86
|
| Rate for Payer: BCN Commercial |
$123.89
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$150.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$159.80
|
| Rate for Payer: Healthscope Whirlpool |
$155.01
|
| Rate for Payer: Mclaren Commercial |
$143.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.83
|
| Rate for Payer: Nomi Health Commercial |
$131.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$140.02
|
| Rate for Payer: Priority Health Narrow Network |
$112.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$140.62
|
|
|
SODIUM BICARBONATE 650 MG TABLET
|
Facility
|
IP
|
$277.30
|
|
|
Service Code
|
NDC 77333083110
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.24 |
| Max. Negotiated Rate |
$277.30 |
| Rate for Payer: Aetna Commercial |
$249.57
|
| Rate for Payer: ASR ASR |
$268.98
|
| Rate for Payer: ASR Commercial |
$268.98
|
| Rate for Payer: BCBS Trust/PPO |
$225.97
|
| Rate for Payer: BCN Commercial |
$214.99
|
| Rate for Payer: Cash Price |
$221.84
|
| Rate for Payer: Cofinity Commercial |
$260.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.84
|
| Rate for Payer: Healthscope Commercial |
$277.30
|
| Rate for Payer: Healthscope Whirlpool |
$268.98
|
| Rate for Payer: Mclaren Commercial |
$249.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.70
|
| Rate for Payer: Nomi Health Commercial |
$227.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.02
|
|
