|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 50268074011
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: Aetna Medicare |
$1.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: BCBS Complete |
$1.01
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.14
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: Priority Health SBD |
$1.59
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$192.85
|
|
|
Service Code
|
NDC 00904640161
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.14 |
| Max. Negotiated Rate |
$173.56 |
| Rate for Payer: Aetna Commercial |
$163.92
|
| Rate for Payer: Aetna Medicare |
$96.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.35
|
| Rate for Payer: BCBS Complete |
$77.14
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$135.00
|
| Rate for Payer: Cofinity Commercial |
$165.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: PHP Commercial |
$163.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health SBD |
$121.50
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$230.85
|
|
|
Service Code
|
NDC 68084029901
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.34 |
| Max. Negotiated Rate |
$207.76 |
| Rate for Payer: Aetna Commercial |
$196.22
|
| Rate for Payer: Aetna Medicare |
$115.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.05
|
| Rate for Payer: BCBS Complete |
$92.34
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$161.60
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$207.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health SBD |
$145.44
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$192.85
|
|
|
Service Code
|
NDC 00904640161
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.50 |
| Max. Negotiated Rate |
$173.56 |
| Rate for Payer: Aetna Commercial |
$163.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.35
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$135.00
|
| Rate for Payer: Cofinity Commercial |
$165.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: PHP Commercial |
$163.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health SBD |
$121.50
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
NDC 63739056710
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.60 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna Medicare |
$152.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.60
|
| Rate for Payer: BCBS Complete |
$121.60
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cofinity Commercial |
$212.80
|
| Rate for Payer: Cofinity Commercial |
$261.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$212.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.20
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.40
|
| Rate for Payer: PHP Commercial |
$258.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.60
|
| Rate for Payer: Priority Health SBD |
$191.52
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 50268074011
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.14
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: Priority Health SBD |
$1.59
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$288.80
|
|
|
Service Code
|
NDC 51079029420
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.52 |
| Max. Negotiated Rate |
$259.92 |
| Rate for Payer: Aetna Commercial |
$245.48
|
| Rate for Payer: Aetna Medicare |
$144.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.72
|
| Rate for Payer: BCBS Complete |
$115.52
|
| Rate for Payer: Cash Price |
$231.04
|
| Rate for Payer: Cofinity Commercial |
$202.16
|
| Rate for Payer: Cofinity Commercial |
$248.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$202.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.04
|
| Rate for Payer: Healthscope Commercial |
$259.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.48
|
| Rate for Payer: PHP Commercial |
$245.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.72
|
| Rate for Payer: Priority Health SBD |
$181.94
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$288.80
|
|
|
Service Code
|
NDC 51079029420
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$181.94 |
| Max. Negotiated Rate |
$259.92 |
| Rate for Payer: Aetna Commercial |
$245.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.72
|
| Rate for Payer: Cash Price |
$231.04
|
| Rate for Payer: Cofinity Commercial |
$202.16
|
| Rate for Payer: Cofinity Commercial |
$248.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$202.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.04
|
| Rate for Payer: Healthscope Commercial |
$259.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$245.48
|
| Rate for Payer: PHP Commercial |
$245.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.72
|
| Rate for Payer: Priority Health SBD |
$181.94
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$262.26
|
|
|
Service Code
|
NDC 62756016081
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.22 |
| Max. Negotiated Rate |
$236.03 |
| Rate for Payer: Aetna Commercial |
$222.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.47
|
| Rate for Payer: Cash Price |
$209.81
|
| Rate for Payer: Cofinity Commercial |
$183.58
|
| Rate for Payer: Cofinity Commercial |
$225.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.81
|
| Rate for Payer: Healthscope Commercial |
$236.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.92
|
| Rate for Payer: PHP Commercial |
$222.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.47
|
| Rate for Payer: Priority Health SBD |
$165.22
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$262.26
|
|
|
Service Code
|
NDC 62756016081
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.90 |
| Max. Negotiated Rate |
$236.03 |
| Rate for Payer: Aetna Commercial |
$222.92
|
| Rate for Payer: Aetna Medicare |
$131.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.47
|
| Rate for Payer: BCBS Complete |
$104.90
|
| Rate for Payer: Cash Price |
$209.81
|
| Rate for Payer: Cofinity Commercial |
$183.58
|
| Rate for Payer: Cofinity Commercial |
$225.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.81
|
| Rate for Payer: Healthscope Commercial |
$236.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.92
|
| Rate for Payer: PHP Commercial |
$222.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.47
|
| Rate for Payer: Priority Health SBD |
$165.22
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$230.85
|
|
|
Service Code
|
NDC 68084029901
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.44 |
| Max. Negotiated Rate |
$207.76 |
| Rate for Payer: Aetna Commercial |
$196.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.05
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$161.60
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$207.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health SBD |
$145.44
|
|
|
TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$911.49
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
168856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$820.34 |
| Rate for Payer: Aetna Commercial |
$774.77
|
| Rate for Payer: Aetna Commercial |
$774.78
|
| Rate for Payer: Aetna Medicare |
$0.42
|
| Rate for Payer: Aetna Medicare |
$0.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$592.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$592.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.50
|
| Rate for Payer: BCBS Complete |
$0.23
|
| Rate for Payer: BCBS Complete |
$0.23
|
| Rate for Payer: BCBS MAPPO |
$0.40
|
| Rate for Payer: BCBS MAPPO |
$0.40
|
| Rate for Payer: BCBS Trust/PPO |
$1.05
|
| Rate for Payer: BCBS Trust/PPO |
$1.05
|
| Rate for Payer: BCN Commercial |
$1.05
|
| Rate for Payer: BCN Commercial |
$1.05
|
| Rate for Payer: BCN Medicare Advantage |
$0.40
|
| Rate for Payer: BCN Medicare Advantage |
$0.40
|
| Rate for Payer: Cash Price |
$729.20
|
| Rate for Payer: Cash Price |
$729.20
|
| Rate for Payer: Cash Price |
$729.19
|
| Rate for Payer: Cash Price |
$729.19
|
| Rate for Payer: Cofinity Commercial |
$638.04
|
| Rate for Payer: Cofinity Commercial |
$783.89
|
| Rate for Payer: Cofinity Commercial |
$638.05
|
| Rate for Payer: Cofinity Commercial |
$783.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$638.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$638.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$729.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$729.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.40
|
| Rate for Payer: Healthscope Commercial |
$820.35
|
| Rate for Payer: Healthscope Commercial |
$820.34
|
| Rate for Payer: Mclaren Medicaid |
$0.21
|
| Rate for Payer: Mclaren Medicaid |
$0.21
|
| Rate for Payer: Mclaren Medicare |
$0.40
|
| Rate for Payer: Mclaren Medicare |
$0.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.42
|
| Rate for Payer: Meridian Medicaid |
$0.23
|
| Rate for Payer: Meridian Medicaid |
$0.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$774.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$774.77
|
| Rate for Payer: Nomi Health Commercial |
$1.20
|
| Rate for Payer: Nomi Health Commercial |
$1.20
|
| Rate for Payer: PACE Medicare |
$0.38
|
| Rate for Payer: PACE Medicare |
$0.38
|
| Rate for Payer: PACE SWMI |
$0.40
|
| Rate for Payer: PACE SWMI |
$0.40
|
| Rate for Payer: PHP Commercial |
$774.77
|
| Rate for Payer: PHP Commercial |
$774.78
|
| Rate for Payer: PHP Medicare Advantage |
$0.40
|
| Rate for Payer: PHP Medicare Advantage |
$0.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$592.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$592.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.13
|
| Rate for Payer: Priority Health Medicare |
$0.40
|
| Rate for Payer: Priority Health Medicare |
$0.40
|
| Rate for Payer: Priority Health Narrow Network |
$0.90
|
| Rate for Payer: Priority Health Narrow Network |
$0.90
|
| Rate for Payer: Priority Health SBD |
$574.24
|
| Rate for Payer: Priority Health SBD |
$574.24
|
| Rate for Payer: Railroad Medicare Medicare |
$0.40
|
| Rate for Payer: Railroad Medicare Medicare |
$0.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.40
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.40
|
| Rate for Payer: UHC Medicare Advantage |
$0.40
|
| Rate for Payer: UHC Medicare Advantage |
$0.40
|
| Rate for Payer: UHCCP Medicaid |
$0.23
|
| Rate for Payer: UHCCP Medicaid |
$0.23
|
| Rate for Payer: VA VA |
$0.40
|
| Rate for Payer: VA VA |
$0.40
|
|
|
TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$911.49
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
168856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$574.24 |
| Max. Negotiated Rate |
$820.34 |
| Rate for Payer: Aetna Commercial |
$774.77
|
| Rate for Payer: Aetna Commercial |
$774.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$592.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$592.48
|
| Rate for Payer: Cash Price |
$729.19
|
| Rate for Payer: Cash Price |
$729.20
|
| Rate for Payer: Cofinity Commercial |
$638.04
|
| Rate for Payer: Cofinity Commercial |
$638.05
|
| Rate for Payer: Cofinity Commercial |
$783.89
|
| Rate for Payer: Cofinity Commercial |
$783.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$638.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$638.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$729.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$729.20
|
| Rate for Payer: Healthscope Commercial |
$820.34
|
| Rate for Payer: Healthscope Commercial |
$820.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$774.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$774.78
|
| Rate for Payer: PHP Commercial |
$774.77
|
| Rate for Payer: PHP Commercial |
$774.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$592.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$592.47
|
| Rate for Payer: Priority Health SBD |
$574.24
|
| Rate for Payer: Priority Health SBD |
$574.24
|
|
|
TEMAZEPAM 7.5 MG CAPSULE
|
Facility
|
IP
|
$384.93
|
|
|
Service Code
|
NDC 63739000333
|
| Hospital Charge Code |
11500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.51 |
| Max. Negotiated Rate |
$346.44 |
| Rate for Payer: Aetna Commercial |
$327.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.20
|
| Rate for Payer: Cash Price |
$307.94
|
| Rate for Payer: Cofinity Commercial |
$269.45
|
| Rate for Payer: Cofinity Commercial |
$331.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.94
|
| Rate for Payer: Healthscope Commercial |
$346.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.19
|
| Rate for Payer: PHP Commercial |
$327.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.20
|
| Rate for Payer: Priority Health SBD |
$242.51
|
|
|
TEMAZEPAM 7.5 MG CAPSULE
|
Facility
|
OP
|
$308.18
|
|
|
Service Code
|
NDC 00904643604
|
| Hospital Charge Code |
11500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.27 |
| Max. Negotiated Rate |
$277.36 |
| Rate for Payer: Aetna Commercial |
$261.95
|
| Rate for Payer: Aetna Medicare |
$154.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.32
|
| Rate for Payer: BCBS Complete |
$123.27
|
| Rate for Payer: Cash Price |
$246.54
|
| Rate for Payer: Cofinity Commercial |
$215.73
|
| Rate for Payer: Cofinity Commercial |
$265.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.54
|
| Rate for Payer: Healthscope Commercial |
$277.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.95
|
| Rate for Payer: PHP Commercial |
$261.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.32
|
| Rate for Payer: Priority Health SBD |
$194.15
|
|
|
TEMAZEPAM 7.5 MG CAPSULE
|
Facility
|
OP
|
$2,127.84
|
|
|
Service Code
|
NDC 00378311001
|
| Hospital Charge Code |
11500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$851.14 |
| Max. Negotiated Rate |
$1,915.06 |
| Rate for Payer: Aetna Commercial |
$1,808.66
|
| Rate for Payer: Aetna Medicare |
$1,063.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,383.10
|
| Rate for Payer: BCBS Complete |
$851.14
|
| Rate for Payer: Cash Price |
$1,702.27
|
| Rate for Payer: Cofinity Commercial |
$1,489.49
|
| Rate for Payer: Cofinity Commercial |
$1,829.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,489.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,702.27
|
| Rate for Payer: Healthscope Commercial |
$1,915.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,808.66
|
| Rate for Payer: PHP Commercial |
$1,808.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,383.10
|
| Rate for Payer: Priority Health SBD |
$1,340.54
|
|
|
TEMAZEPAM 7.5 MG CAPSULE
|
Facility
|
IP
|
$308.18
|
|
|
Service Code
|
NDC 00904643604
|
| Hospital Charge Code |
11500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.15 |
| Max. Negotiated Rate |
$277.36 |
| Rate for Payer: Aetna Commercial |
$261.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.32
|
| Rate for Payer: Cash Price |
$246.54
|
| Rate for Payer: Cofinity Commercial |
$215.73
|
| Rate for Payer: Cofinity Commercial |
$265.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.54
|
| Rate for Payer: Healthscope Commercial |
$277.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.95
|
| Rate for Payer: PHP Commercial |
$261.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.32
|
| Rate for Payer: Priority Health SBD |
$194.15
|
|
|
TEMAZEPAM 7.5 MG CAPSULE
|
Facility
|
IP
|
$2,127.84
|
|
|
Service Code
|
NDC 00378311001
|
| Hospital Charge Code |
11500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,340.54 |
| Max. Negotiated Rate |
$1,915.06 |
| Rate for Payer: Aetna Commercial |
$1,808.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,383.10
|
| Rate for Payer: Cash Price |
$1,702.27
|
| Rate for Payer: Cofinity Commercial |
$1,489.49
|
| Rate for Payer: Cofinity Commercial |
$1,829.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,489.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,702.27
|
| Rate for Payer: Healthscope Commercial |
$1,915.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,808.66
|
| Rate for Payer: PHP Commercial |
$1,808.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,383.10
|
| Rate for Payer: Priority Health SBD |
$1,340.54
|
|
|
TEMAZEPAM 7.5 MG CAPSULE
|
Facility
|
OP
|
$384.93
|
|
|
Service Code
|
NDC 63739000333
|
| Hospital Charge Code |
11500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.97 |
| Max. Negotiated Rate |
$346.44 |
| Rate for Payer: Aetna Commercial |
$327.19
|
| Rate for Payer: Aetna Medicare |
$192.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.20
|
| Rate for Payer: BCBS Complete |
$153.97
|
| Rate for Payer: Cash Price |
$307.94
|
| Rate for Payer: Cofinity Commercial |
$269.45
|
| Rate for Payer: Cofinity Commercial |
$331.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.94
|
| Rate for Payer: Healthscope Commercial |
$346.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.19
|
| Rate for Payer: PHP Commercial |
$327.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.20
|
| Rate for Payer: Priority Health SBD |
$242.51
|
|
|
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN
|
Facility
|
IP
|
$7,785.57
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
82228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,904.91 |
| Max. Negotiated Rate |
$7,007.01 |
| Rate for Payer: Aetna Commercial |
$6,617.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,060.62
|
| Rate for Payer: Cash Price |
$6,228.46
|
| Rate for Payer: Cofinity Commercial |
$5,449.90
|
| Rate for Payer: Cofinity Commercial |
$6,695.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,449.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,228.46
|
| Rate for Payer: Healthscope Commercial |
$7,007.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,617.73
|
| Rate for Payer: PHP Commercial |
$6,617.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,060.62
|
| Rate for Payer: Priority Health SBD |
$4,904.91
|
|
|
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN
|
Facility
|
OP
|
$7,785.57
|
|
|
Service Code
|
HCPCS J9330
|
| Hospital Charge Code |
82228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$7,007.01 |
| Rate for Payer: Aetna Commercial |
$6,617.73
|
| Rate for Payer: Aetna Medicare |
$30.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,060.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$36.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$36.90
|
| Rate for Payer: BCBS Complete |
$16.61
|
| Rate for Payer: BCBS MAPPO |
$29.52
|
| Rate for Payer: BCBS Trust/PPO |
$90.97
|
| Rate for Payer: BCN Commercial |
$90.97
|
| Rate for Payer: BCN Medicare Advantage |
$29.52
|
| Rate for Payer: Cash Price |
$6,228.46
|
| Rate for Payer: Cash Price |
$6,228.46
|
| Rate for Payer: Cofinity Commercial |
$6,695.59
|
| Rate for Payer: Cofinity Commercial |
$5,449.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,449.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,228.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29.52
|
| Rate for Payer: Healthscope Commercial |
$7,007.01
|
| Rate for Payer: Mclaren Medicaid |
$15.82
|
| Rate for Payer: Mclaren Medicare |
$29.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31.00
|
| Rate for Payer: Meridian Medicaid |
$16.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,617.73
|
| Rate for Payer: Nomi Health Commercial |
$88.56
|
| Rate for Payer: PACE Medicare |
$28.04
|
| Rate for Payer: PACE SWMI |
$29.52
|
| Rate for Payer: PHP Commercial |
$6,617.73
|
| Rate for Payer: PHP Medicare Advantage |
$29.52
|
| Rate for Payer: Priority Health Choice Medicaid |
$15.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,060.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$92.69
|
| Rate for Payer: Priority Health Medicare |
$29.52
|
| Rate for Payer: Priority Health Narrow Network |
$74.15
|
| Rate for Payer: Priority Health SBD |
$4,904.91
|
| Rate for Payer: Railroad Medicare Medicare |
$29.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$83.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$29.52
|
| Rate for Payer: UHC Medicare Advantage |
$29.52
|
| Rate for Payer: UHCCP Medicaid |
$16.62
|
| Rate for Payer: VA VA |
$29.52
|
|
|
TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)
|
Facility
|
OP
|
$4,928.37
|
|
|
Service Code
|
CPT 26055
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$310.20 |
| Max. Negotiated Rate |
$4,928.37 |
| Rate for Payer: Aetna Medicare |
$1,630.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,960.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,960.06
|
| Rate for Payer: BCBS Complete |
$882.50
|
| Rate for Payer: BCBS MAPPO |
$1,568.05
|
| Rate for Payer: BCBS Trust/PPO |
$882.60
|
| Rate for Payer: BCN Commercial |
$882.60
|
| Rate for Payer: BCN Medicare Advantage |
$1,568.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,568.05
|
| Rate for Payer: Mclaren Medicaid |
$840.47
|
| Rate for Payer: Mclaren Medicare |
$1,568.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,646.45
|
| Rate for Payer: Meridian Medicaid |
$882.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,803.26
|
| Rate for Payer: Nomi Health Commercial |
$3,292.90
|
| Rate for Payer: PACE Medicare |
$1,489.65
|
| Rate for Payer: PACE SWMI |
$1,568.05
|
| Rate for Payer: PHP Medicare Advantage |
$1,568.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$840.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,928.37
|
| Rate for Payer: Priority Health Medicare |
$1,568.05
|
| Rate for Payer: Priority Health Narrow Network |
$3,942.70
|
| Rate for Payer: Railroad Medicare Medicare |
$1,568.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$310.20
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,568.05
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,568.05
|
| Rate for Payer: UHCCP Medicaid |
$882.81
|
| Rate for Payer: VA VA |
$1,568.05
|
|
|
TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON
|
Facility
|
OP
|
$9,991.56
|
|
|
Service Code
|
CPT 25310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$663.37 |
| Max. Negotiated Rate |
$9,991.56 |
| Rate for Payer: Aetna Medicare |
$3,306.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,973.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,973.75
|
| Rate for Payer: BCBS Complete |
$1,789.14
|
| Rate for Payer: BCBS MAPPO |
$3,179.00
|
| Rate for Payer: BCBS Trust/PPO |
$1,515.87
|
| Rate for Payer: BCN Commercial |
$1,515.87
|
| Rate for Payer: BCN Medicare Advantage |
$3,179.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,179.00
|
| Rate for Payer: Mclaren Medicaid |
$1,703.94
|
| Rate for Payer: Mclaren Medicare |
$3,179.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,337.95
|
| Rate for Payer: Meridian Medicaid |
$1,789.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,655.85
|
| Rate for Payer: Nomi Health Commercial |
$6,675.90
|
| Rate for Payer: PACE Medicare |
$3,020.05
|
| Rate for Payer: PACE SWMI |
$3,179.00
|
| Rate for Payer: PHP Medicare Advantage |
$3,179.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,991.56
|
| Rate for Payer: Priority Health Medicare |
$3,179.00
|
| Rate for Payer: Priority Health Narrow Network |
$7,993.25
|
| Rate for Payer: Railroad Medicare Medicare |
$3,179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$663.37
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,179.00
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,179.00
|
| Rate for Payer: UHCCP Medicaid |
$1,789.78
|
| Rate for Payer: VA VA |
$3,179.00
|
|
|
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$29,932.38
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
186094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.06 |
| Max. Negotiated Rate |
$26,939.14 |
| Rate for Payer: Aetna Commercial |
$25,442.52
|
| Rate for Payer: Aetna Medicare |
$168.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,456.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$203.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$203.04
|
| Rate for Payer: BCBS Complete |
$91.42
|
| Rate for Payer: BCBS MAPPO |
$162.43
|
| Rate for Payer: BCBS Trust/PPO |
$457.55
|
| Rate for Payer: BCN Commercial |
$457.55
|
| Rate for Payer: BCN Medicare Advantage |
$162.43
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cofinity Commercial |
$25,741.85
|
| Rate for Payer: Cofinity Commercial |
$20,952.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,952.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,945.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$162.43
|
| Rate for Payer: Healthscope Commercial |
$26,939.14
|
| Rate for Payer: Mclaren Medicaid |
$87.06
|
| Rate for Payer: Mclaren Medicare |
$162.43
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$170.55
|
| Rate for Payer: Meridian Medicaid |
$91.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$186.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,442.52
|
| Rate for Payer: Nomi Health Commercial |
$487.29
|
| Rate for Payer: PACE Medicare |
$154.31
|
| Rate for Payer: PACE SWMI |
$162.43
|
| Rate for Payer: PHP Commercial |
$25,442.52
|
| Rate for Payer: PHP Medicare Advantage |
$162.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$87.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,456.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$453.93
|
| Rate for Payer: Priority Health Medicare |
$162.43
|
| Rate for Payer: Priority Health Narrow Network |
$363.14
|
| Rate for Payer: Priority Health SBD |
$18,857.40
|
| Rate for Payer: Railroad Medicare Medicare |
$162.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$457.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$162.43
|
| Rate for Payer: UHC Medicare Advantage |
$162.43
|
| Rate for Payer: UHCCP Medicaid |
$91.45
|
| Rate for Payer: VA VA |
$162.43
|
|
|
TENECTEPLASE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$29,932.38
|
|
|
Service Code
|
HCPCS J3101
|
| Hospital Charge Code |
186094
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,857.40 |
| Max. Negotiated Rate |
$26,939.14 |
| Rate for Payer: Aetna Commercial |
$25,442.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,456.05
|
| Rate for Payer: Cash Price |
$23,945.90
|
| Rate for Payer: Cofinity Commercial |
$20,952.67
|
| Rate for Payer: Cofinity Commercial |
$25,741.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,952.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,945.90
|
| Rate for Payer: Healthscope Commercial |
$26,939.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,442.52
|
| Rate for Payer: PHP Commercial |
$25,442.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,456.05
|
| Rate for Payer: Priority Health SBD |
$18,857.40
|
|
