|
ALTEPLASE 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,166.68 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,185.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,743.40
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
|
|
ALTEPLASE 100 MG IV INFUSION FOR STROKE
|
Facility
|
OP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150807
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna Medicare |
$95.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.35
|
| Rate for Payer: BCBS Complete |
$51.48
|
| Rate for Payer: BCBS MAPPO |
$91.48
|
| Rate for Payer: BCBS Trust/PPO |
$258.37
|
| Rate for Payer: BCN Commercial |
$258.37
|
| Rate for Payer: BCN Medicare Advantage |
$91.48
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,185.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.48
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Mclaren Medicaid |
$49.03
|
| Rate for Payer: Mclaren Medicare |
$91.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.05
|
| Rate for Payer: Meridian Medicaid |
$51.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24,510.60
|
| Rate for Payer: Nomi Health Commercial |
$274.44
|
| Rate for Payer: PACE Medicare |
$86.91
|
| Rate for Payer: PACE SWMI |
$91.48
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: PHP Medicare Advantage |
$91.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,743.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.25
|
| Rate for Payer: Priority Health Medicare |
$91.48
|
| Rate for Payer: Priority Health Narrow Network |
$210.60
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
| Rate for Payer: Railroad Medicare Medicare |
$91.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.48
|
| Rate for Payer: UHC Medicare Advantage |
$91.48
|
| Rate for Payer: UHCCP Medicaid |
$51.50
|
| Rate for Payer: VA VA |
$91.48
|
|
|
ALTEPLASE 100 MG IV INFUSION FOR STROKE
|
Facility
|
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150807
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,166.68 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,185.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,743.40
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
|
|
ALTEPLASE 100MG IV SOLUTION FOR PE
|
Facility
|
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,166.68 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,185.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,743.40
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
|
|
ALTEPLASE 100MG IV SOLUTION FOR PE
|
Facility
|
OP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna Medicare |
$95.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.35
|
| Rate for Payer: BCBS Complete |
$51.48
|
| Rate for Payer: BCBS MAPPO |
$91.48
|
| Rate for Payer: BCBS Trust/PPO |
$258.37
|
| Rate for Payer: BCN Commercial |
$258.37
|
| Rate for Payer: BCN Medicare Advantage |
$91.48
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,185.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.48
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Mclaren Medicaid |
$49.03
|
| Rate for Payer: Mclaren Medicare |
$91.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.05
|
| Rate for Payer: Meridian Medicaid |
$51.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24,510.60
|
| Rate for Payer: Nomi Health Commercial |
$274.44
|
| Rate for Payer: PACE Medicare |
$86.91
|
| Rate for Payer: PACE SWMI |
$91.48
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: PHP Medicare Advantage |
$91.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,743.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.25
|
| Rate for Payer: Priority Health Medicare |
$91.48
|
| Rate for Payer: Priority Health Narrow Network |
$210.60
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
| Rate for Payer: Railroad Medicare Medicare |
$91.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.48
|
| Rate for Payer: UHC Medicare Advantage |
$91.48
|
| Rate for Payer: UHCCP Medicaid |
$51.50
|
| Rate for Payer: VA VA |
$91.48
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION
|
Facility
|
OP
|
$640.89
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$576.80 |
| Rate for Payer: Aetna Commercial |
$544.76
|
| Rate for Payer: Aetna Commercial |
$544.78
|
| Rate for Payer: Aetna Medicare |
$95.14
|
| Rate for Payer: Aetna Medicare |
$95.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$416.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$416.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.35
|
| Rate for Payer: BCBS Complete |
$51.48
|
| Rate for Payer: BCBS Complete |
$51.48
|
| Rate for Payer: BCBS MAPPO |
$91.48
|
| Rate for Payer: BCBS MAPPO |
$91.48
|
| Rate for Payer: BCBS Trust/PPO |
$258.37
|
| Rate for Payer: BCBS Trust/PPO |
$258.37
|
| Rate for Payer: BCN Commercial |
$258.37
|
| Rate for Payer: BCN Commercial |
$258.37
|
| Rate for Payer: BCN Medicare Advantage |
$91.48
|
| Rate for Payer: BCN Medicare Advantage |
$91.48
|
| Rate for Payer: Cash Price |
$512.74
|
| Rate for Payer: Cash Price |
$512.74
|
| Rate for Payer: Cash Price |
$512.71
|
| Rate for Payer: Cash Price |
$512.71
|
| Rate for Payer: Cofinity Commercial |
$448.62
|
| Rate for Payer: Cofinity Commercial |
$551.19
|
| Rate for Payer: Cofinity Commercial |
$448.64
|
| Rate for Payer: Cofinity Commercial |
$551.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$448.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$448.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$512.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$512.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.48
|
| Rate for Payer: Healthscope Commercial |
$576.83
|
| Rate for Payer: Healthscope Commercial |
$576.80
|
| Rate for Payer: Mclaren Medicaid |
$49.03
|
| Rate for Payer: Mclaren Medicaid |
$49.03
|
| Rate for Payer: Mclaren Medicare |
$91.48
|
| Rate for Payer: Mclaren Medicare |
$91.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.05
|
| Rate for Payer: Meridian Medicaid |
$51.48
|
| Rate for Payer: Meridian Medicaid |
$51.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$544.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$544.76
|
| Rate for Payer: Nomi Health Commercial |
$274.44
|
| Rate for Payer: Nomi Health Commercial |
$274.44
|
| Rate for Payer: PACE Medicare |
$86.91
|
| Rate for Payer: PACE Medicare |
$86.91
|
| Rate for Payer: PACE SWMI |
$91.48
|
| Rate for Payer: PACE SWMI |
$91.48
|
| Rate for Payer: PHP Commercial |
$544.76
|
| Rate for Payer: PHP Commercial |
$544.78
|
| Rate for Payer: PHP Medicare Advantage |
$91.48
|
| Rate for Payer: PHP Medicare Advantage |
$91.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$416.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$416.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.25
|
| Rate for Payer: Priority Health Medicare |
$91.48
|
| Rate for Payer: Priority Health Medicare |
$91.48
|
| Rate for Payer: Priority Health Narrow Network |
$210.60
|
| Rate for Payer: Priority Health Narrow Network |
$210.60
|
| Rate for Payer: Priority Health SBD |
$403.78
|
| Rate for Payer: Priority Health SBD |
$403.76
|
| Rate for Payer: Railroad Medicare Medicare |
$91.48
|
| Rate for Payer: Railroad Medicare Medicare |
$91.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.48
|
| Rate for Payer: UHC Medicare Advantage |
$91.48
|
| Rate for Payer: UHC Medicare Advantage |
$91.48
|
| Rate for Payer: UHCCP Medicaid |
$51.50
|
| Rate for Payer: UHCCP Medicaid |
$51.50
|
| Rate for Payer: VA VA |
$91.48
|
| Rate for Payer: VA VA |
$91.48
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION
|
Facility
|
IP
|
$640.92
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
31310
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$403.78 |
| Max. Negotiated Rate |
$576.83 |
| Rate for Payer: Aetna Commercial |
$544.78
|
| Rate for Payer: Aetna Commercial |
$544.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$416.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$416.58
|
| Rate for Payer: Cash Price |
$512.74
|
| Rate for Payer: Cash Price |
$512.71
|
| Rate for Payer: Cofinity Commercial |
$551.19
|
| Rate for Payer: Cofinity Commercial |
$448.62
|
| Rate for Payer: Cofinity Commercial |
$551.17
|
| Rate for Payer: Cofinity Commercial |
$448.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$448.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$448.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$512.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$512.74
|
| Rate for Payer: Healthscope Commercial |
$576.83
|
| Rate for Payer: Healthscope Commercial |
$576.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$544.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$544.76
|
| Rate for Payer: PHP Commercial |
$544.76
|
| Rate for Payer: PHP Commercial |
$544.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$416.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$416.60
|
| Rate for Payer: Priority Health SBD |
$403.78
|
| Rate for Payer: Priority Health SBD |
$403.76
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,083.34 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,371.70
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$10,092.60
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$10,092.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,255.30
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,371.70
|
| Rate for Payer: Priority Health SBD |
$9,083.34
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$14,418.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
9003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$12,976.20 |
| Rate for Payer: Aetna Commercial |
$12,255.30
|
| Rate for Payer: Aetna Medicare |
$95.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,371.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.35
|
| Rate for Payer: BCBS Complete |
$51.48
|
| Rate for Payer: BCBS MAPPO |
$91.48
|
| Rate for Payer: BCBS Trust/PPO |
$258.37
|
| Rate for Payer: BCN Commercial |
$258.37
|
| Rate for Payer: BCN Medicare Advantage |
$91.48
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cash Price |
$11,534.40
|
| Rate for Payer: Cofinity Commercial |
$12,399.48
|
| Rate for Payer: Cofinity Commercial |
$10,092.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$10,092.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,534.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.48
|
| Rate for Payer: Healthscope Commercial |
$12,976.20
|
| Rate for Payer: Mclaren Medicaid |
$49.03
|
| Rate for Payer: Mclaren Medicare |
$91.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.05
|
| Rate for Payer: Meridian Medicaid |
$51.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,255.30
|
| Rate for Payer: Nomi Health Commercial |
$274.44
|
| Rate for Payer: PACE Medicare |
$86.91
|
| Rate for Payer: PACE SWMI |
$91.48
|
| Rate for Payer: PHP Commercial |
$12,255.30
|
| Rate for Payer: PHP Medicare Advantage |
$91.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,371.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.25
|
| Rate for Payer: Priority Health Medicare |
$91.48
|
| Rate for Payer: Priority Health Narrow Network |
$210.60
|
| Rate for Payer: Priority Health SBD |
$9,083.34
|
| Rate for Payer: Railroad Medicare Medicare |
$91.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.48
|
| Rate for Payer: UHC Medicare Advantage |
$91.48
|
| Rate for Payer: UHCCP Medicaid |
$51.50
|
| Rate for Payer: VA VA |
$91.48
|
|
|
ALTEPLASE INFUSION FOR CARDIAC ARREST
|
Facility
|
IP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
300766
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,166.68 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,185.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24,510.60
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,743.40
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
|
|
ALTEPLASE INFUSION FOR CARDIAC ARREST
|
Facility
|
OP
|
$28,836.00
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
300766
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$25,952.40 |
| Rate for Payer: Aetna Commercial |
$24,510.60
|
| Rate for Payer: Aetna Medicare |
$95.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,743.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.35
|
| Rate for Payer: BCBS Complete |
$51.48
|
| Rate for Payer: BCBS MAPPO |
$91.48
|
| Rate for Payer: BCBS Trust/PPO |
$258.37
|
| Rate for Payer: BCN Commercial |
$258.37
|
| Rate for Payer: BCN Medicare Advantage |
$91.48
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cash Price |
$23,068.80
|
| Rate for Payer: Cofinity Commercial |
$24,798.96
|
| Rate for Payer: Cofinity Commercial |
$20,185.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,185.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,068.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.48
|
| Rate for Payer: Healthscope Commercial |
$25,952.40
|
| Rate for Payer: Mclaren Medicaid |
$49.03
|
| Rate for Payer: Mclaren Medicare |
$91.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.05
|
| Rate for Payer: Meridian Medicaid |
$51.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24,510.60
|
| Rate for Payer: Nomi Health Commercial |
$274.44
|
| Rate for Payer: PACE Medicare |
$86.91
|
| Rate for Payer: PACE SWMI |
$91.48
|
| Rate for Payer: PHP Commercial |
$24,510.60
|
| Rate for Payer: PHP Medicare Advantage |
$91.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18,743.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.25
|
| Rate for Payer: Priority Health Medicare |
$91.48
|
| Rate for Payer: Priority Health Narrow Network |
$210.60
|
| Rate for Payer: Priority Health SBD |
$18,166.68
|
| Rate for Payer: Railroad Medicare Medicare |
$91.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.48
|
| Rate for Payer: UHC Medicare Advantage |
$91.48
|
| Rate for Payer: UHCCP Medicaid |
$51.50
|
| Rate for Payer: VA VA |
$91.48
|
|
|
ALTEPLASE IV BOLUS (FROM KIT)
|
Facility
|
OP
|
$274.44
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
150840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.03 |
| Max. Negotiated Rate |
$274.44 |
| Rate for Payer: Aetna Medicare |
$95.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.35
|
| Rate for Payer: BCBS Complete |
$51.48
|
| Rate for Payer: BCBS MAPPO |
$91.48
|
| Rate for Payer: BCBS Trust/PPO |
$258.37
|
| Rate for Payer: BCN Commercial |
$258.37
|
| Rate for Payer: BCN Medicare Advantage |
$91.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.48
|
| Rate for Payer: Mclaren Medicaid |
$49.03
|
| Rate for Payer: Mclaren Medicare |
$91.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.05
|
| Rate for Payer: Meridian Medicaid |
$51.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.20
|
| Rate for Payer: Nomi Health Commercial |
$274.44
|
| Rate for Payer: PACE Medicare |
$86.91
|
| Rate for Payer: PACE SWMI |
$91.48
|
| Rate for Payer: PHP Medicare Advantage |
$91.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.25
|
| Rate for Payer: Priority Health Medicare |
$91.48
|
| Rate for Payer: Priority Health Narrow Network |
$210.60
|
| Rate for Payer: Railroad Medicare Medicare |
$91.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.48
|
| Rate for Payer: UHC Medicare Advantage |
$91.48
|
| Rate for Payer: UHCCP Medicaid |
$51.50
|
| Rate for Payer: VA VA |
$91.48
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION
|
Facility
|
IP
|
$28.90
|
|
|
Service Code
|
NDC 00088117112
|
| Hospital Charge Code |
24314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.21 |
| Max. Negotiated Rate |
$26.01 |
| Rate for Payer: Aetna Commercial |
$24.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.78
|
| Rate for Payer: Cash Price |
$23.12
|
| Rate for Payer: Cofinity Commercial |
$20.23
|
| Rate for Payer: Cofinity Commercial |
$24.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.12
|
| Rate for Payer: Healthscope Commercial |
$26.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.56
|
| Rate for Payer: PHP Commercial |
$24.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.78
|
| Rate for Payer: Priority Health SBD |
$18.21
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION
|
Facility
|
OP
|
$28.90
|
|
|
Service Code
|
NDC 00088117112
|
| Hospital Charge Code |
24314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.56 |
| Max. Negotiated Rate |
$26.01 |
| Rate for Payer: Aetna Commercial |
$24.56
|
| Rate for Payer: Aetna Medicare |
$14.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.78
|
| Rate for Payer: BCBS Complete |
$11.56
|
| Rate for Payer: Cash Price |
$23.12
|
| Rate for Payer: Cofinity Commercial |
$20.23
|
| Rate for Payer: Cofinity Commercial |
$24.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.12
|
| Rate for Payer: Healthscope Commercial |
$26.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.56
|
| Rate for Payer: PHP Commercial |
$24.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.78
|
| Rate for Payer: Priority Health SBD |
$18.21
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION
|
Facility
|
IP
|
$14.45
|
|
|
Service Code
|
NDC 00904772714
|
| Hospital Charge Code |
24314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.39
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$10.12
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: PHP Commercial |
$12.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.39
|
| Rate for Payer: Priority Health SBD |
$9.10
|
|
|
ALUMINUM HYDROX-MAGNESIUM CARB 95 MG-358 MG/15 ML ORAL SUSPENSION
|
Facility
|
OP
|
$14.45
|
|
|
Service Code
|
NDC 00904772714
|
| Hospital Charge Code |
24314
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Aetna Medicare |
$7.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.39
|
| Rate for Payer: BCBS Complete |
$5.78
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$10.12
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: PHP Commercial |
$12.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.39
|
| Rate for Payer: Priority Health SBD |
$9.10
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 00904732573
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Aetna Medicare |
$6.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.34
|
| Rate for Payer: BCBS Complete |
$5.13
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Cofinity Commercial |
$8.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.34
|
| Rate for Payer: Priority Health SBD |
$8.08
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$12.83
|
|
|
Service Code
|
NDC 00904732562
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Aetna Medicare |
$6.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.34
|
| Rate for Payer: BCBS Complete |
$5.13
|
| Rate for Payer: Cash Price |
$10.26
|
| Rate for Payer: Cofinity Commercial |
$11.03
|
| Rate for Payer: Cofinity Commercial |
$8.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.26
|
| Rate for Payer: Healthscope Commercial |
$11.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.91
|
| Rate for Payer: PHP Commercial |
$10.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.34
|
| Rate for Payer: Priority Health SBD |
$8.08
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$10.26
|
|
|
Service Code
|
NDC 00904683873
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.10 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna Medicare |
$5.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: BCBS Complete |
$4.10
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.67
|
| Rate for Payer: Priority Health SBD |
$6.46
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$18.23
|
|
|
Service Code
|
NDC 57237031631
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.48 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Aetna Commercial |
$15.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.85
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Commercial |
$12.76
|
| Rate for Payer: Cofinity Commercial |
$15.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$16.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.50
|
| Rate for Payer: PHP Commercial |
$15.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.85
|
| Rate for Payer: Priority Health SBD |
$11.48
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$15.98
|
|
|
Service Code
|
NDC 57896062912
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.39 |
| Max. Negotiated Rate |
$14.38 |
| Rate for Payer: Aetna Commercial |
$13.58
|
| Rate for Payer: Aetna Medicare |
$7.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.39
|
| Rate for Payer: BCBS Complete |
$6.39
|
| Rate for Payer: Cash Price |
$12.78
|
| Rate for Payer: Cofinity Commercial |
$11.19
|
| Rate for Payer: Cofinity Commercial |
$13.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.78
|
| Rate for Payer: Healthscope Commercial |
$14.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.58
|
| Rate for Payer: PHP Commercial |
$13.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.39
|
| Rate for Payer: Priority Health SBD |
$10.07
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$14.38
|
|
|
Service Code
|
NDC 00536131783
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Aetna Commercial |
$12.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.35
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cofinity Commercial |
$10.07
|
| Rate for Payer: Cofinity Commercial |
$12.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.50
|
| Rate for Payer: Healthscope Commercial |
$12.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.22
|
| Rate for Payer: PHP Commercial |
$12.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.35
|
| Rate for Payer: Priority Health SBD |
$9.06
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$13.77
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$12.39 |
| Rate for Payer: Aetna Commercial |
$11.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.95
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cofinity Commercial |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.02
|
| Rate for Payer: Healthscope Commercial |
$12.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.70
|
| Rate for Payer: PHP Commercial |
$11.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: Priority Health SBD |
$8.68
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$14.38
|
|
|
Service Code
|
NDC 00536131783
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Aetna Commercial |
$12.22
|
| Rate for Payer: Aetna Medicare |
$7.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.35
|
| Rate for Payer: BCBS Complete |
$5.75
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cofinity Commercial |
$10.07
|
| Rate for Payer: Cofinity Commercial |
$12.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.50
|
| Rate for Payer: Healthscope Commercial |
$12.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.22
|
| Rate for Payer: PHP Commercial |
$12.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.35
|
| Rate for Payer: Priority Health SBD |
$9.06
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$13.77
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$12.39 |
| Rate for Payer: Aetna Commercial |
$11.70
|
| Rate for Payer: Aetna Medicare |
$6.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.95
|
| Rate for Payer: BCBS Complete |
$5.51
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Cofinity Commercial |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.02
|
| Rate for Payer: Healthscope Commercial |
$12.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.70
|
| Rate for Payer: PHP Commercial |
$11.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: Priority Health SBD |
$8.68
|
|
