|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)
|
Facility
|
OP
|
$11,358.48
|
|
|
Service Code
|
CPT 52352
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,836.94 |
| Max. Negotiated Rate |
$11,358.48 |
| Rate for Payer: Aetna Medicare |
$3,652.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,390.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,390.39
|
| Rate for Payer: BCBS Complete |
$1,928.96
|
| Rate for Payer: BCBS MAPPO |
$3,512.31
|
| Rate for Payer: BCBS Trust/PPO |
$2,010.14
|
| Rate for Payer: BCN Commercial |
$2,010.14
|
| Rate for Payer: BCN Medicare Advantage |
$3,512.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,512.31
|
| Rate for Payer: Mclaren Medicaid |
$1,836.94
|
| Rate for Payer: Mclaren Medicare |
$3,512.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,687.93
|
| Rate for Payer: Meridian Medicaid |
$3,687.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,039.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,863.54
|
| Rate for Payer: Nomi Health Commercial |
$10,536.93
|
| Rate for Payer: PACE Medicare |
$3,336.69
|
| Rate for Payer: PACE SWMI |
$3,512.31
|
| Rate for Payer: PHP Medicare Advantage |
$3,512.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,836.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$11,358.48
|
| Rate for Payer: Priority Health Medicare |
$3,512.31
|
| Rate for Payer: Priority Health Tiered Network |
$9,086.78
|
| Rate for Payer: Railroad Medicare Medicare |
$3,512.31
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,512.31
|
| Rate for Payer: UHC Medicaid |
$1,836.94
|
| Rate for Payer: UHCCP Medicaid |
$1,836.94
|
| Rate for Payer: VA VA |
$3,512.31
|
|
|
CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)
|
Facility
|
OP
|
$11,358.48
|
|
|
Service Code
|
CPT 52344
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,352.02 |
| Max. Negotiated Rate |
$11,358.48 |
| Rate for Payer: Aetna Medicare |
$3,652.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,390.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,390.39
|
| Rate for Payer: BCBS Complete |
$1,928.96
|
| Rate for Payer: BCBS MAPPO |
$3,512.31
|
| Rate for Payer: BCBS Trust/PPO |
$1,352.02
|
| Rate for Payer: BCN Commercial |
$1,352.02
|
| Rate for Payer: BCN Medicare Advantage |
$3,512.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,512.31
|
| Rate for Payer: Mclaren Medicaid |
$1,836.94
|
| Rate for Payer: Mclaren Medicare |
$3,512.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,687.93
|
| Rate for Payer: Meridian Medicaid |
$3,687.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,039.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,863.54
|
| Rate for Payer: Nomi Health Commercial |
$10,536.93
|
| Rate for Payer: PACE Medicare |
$3,336.69
|
| Rate for Payer: PACE SWMI |
$3,512.31
|
| Rate for Payer: PHP Medicare Advantage |
$3,512.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,836.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$11,358.48
|
| Rate for Payer: Priority Health Medicare |
$3,512.31
|
| Rate for Payer: Priority Health Tiered Network |
$9,086.78
|
| Rate for Payer: Railroad Medicare Medicare |
$3,512.31
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,512.31
|
| Rate for Payer: UHC Medicaid |
$1,836.94
|
| Rate for Payer: UHCCP Medicaid |
$1,836.94
|
| Rate for Payer: VA VA |
$3,512.31
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION
|
Facility
|
OP
|
$212.25
|
|
|
Service Code
|
HCPCS J9100
|
| Hospital Charge Code |
20156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$191.03 |
| Rate for Payer: Aetna Commercial |
$180.41
|
| Rate for Payer: Aetna Medicare |
$106.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.96
|
| Rate for Payer: BCBS Complete |
$84.90
|
| Rate for Payer: BCBS Trust/PPO |
$2.09
|
| Rate for Payer: BCN Commercial |
$2.09
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cofinity Advantage |
$148.57
|
| Rate for Payer: Cofinity Commercial |
$182.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.80
|
| Rate for Payer: Healthscope Commercial |
$191.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$169.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$159.19
|
| Rate for Payer: PHP Commercial |
$180.41
|
| Rate for Payer: Priority Health SBD |
$133.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.39
|
| Rate for Payer: UHC Core |
$1.39
|
| Rate for Payer: UHC Exchange |
$1.39
|
|
|
CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$212.25
|
|
|
Service Code
|
HCPCS J9100
|
| Hospital Charge Code |
20156
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.72 |
| Max. Negotiated Rate |
$191.03 |
| Rate for Payer: Aetna Commercial |
$180.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.96
|
| Rate for Payer: Cash Price |
$169.80
|
| Rate for Payer: Cofinity Advantage |
$148.57
|
| Rate for Payer: Cofinity Commercial |
$182.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.80
|
| Rate for Payer: Healthscope Commercial |
$191.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$159.19
|
| Rate for Payer: PHP Commercial |
$180.41
|
| Rate for Payer: Priority Health SBD |
$133.72
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$679.99
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.24 |
| Max. Negotiated Rate |
$611.99 |
| Rate for Payer: Aetna Commercial |
$577.99
|
| Rate for Payer: Aetna Medicare |
$340.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$441.99
|
| Rate for Payer: BCBS Complete |
$272.00
|
| Rate for Payer: Cash Price |
$543.99
|
| Rate for Payer: Cofinity Advantage |
$475.99
|
| Rate for Payer: Cofinity Commercial |
$584.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$543.99
|
| Rate for Payer: Healthscope Commercial |
$611.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$543.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$577.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$509.99
|
| Rate for Payer: PHP Commercial |
$577.99
|
| Rate for Payer: Priority Health SBD |
$428.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$441.99
|
| Rate for Payer: UHC Core |
$354.27
|
| Rate for Payer: UHC Exchange |
$267.24
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$535.68
|
|
|
Service Code
|
NDC 31722062160
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.52 |
| Max. Negotiated Rate |
$482.11 |
| Rate for Payer: Aetna Commercial |
$455.33
|
| Rate for Payer: Aetna Medicare |
$267.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.19
|
| Rate for Payer: BCBS Complete |
$214.27
|
| Rate for Payer: Cash Price |
$428.54
|
| Rate for Payer: Cofinity Advantage |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$428.54
|
| Rate for Payer: Healthscope Commercial |
$482.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$428.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$455.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$401.76
|
| Rate for Payer: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health SBD |
$337.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$348.19
|
| Rate for Payer: UHC Core |
$279.09
|
| Rate for Payer: UHC Exchange |
$210.52
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
IP
|
$535.68
|
|
|
Service Code
|
NDC 31722062160
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$337.48 |
| Max. Negotiated Rate |
$482.11 |
| Rate for Payer: Aetna Commercial |
$455.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.19
|
| Rate for Payer: Cash Price |
$428.54
|
| Rate for Payer: Cofinity Advantage |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$428.54
|
| Rate for Payer: Healthscope Commercial |
$482.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$455.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$401.76
|
| Rate for Payer: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health SBD |
$337.48
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$9.31
|
|
|
Service Code
|
NDC 60687074411
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$8.38 |
| Rate for Payer: Aetna Commercial |
$7.91
|
| Rate for Payer: Aetna Medicare |
$4.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.05
|
| Rate for Payer: BCBS Complete |
$3.72
|
| Rate for Payer: Cash Price |
$7.45
|
| Rate for Payer: Cofinity Advantage |
$6.52
|
| Rate for Payer: Cofinity Commercial |
$8.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.45
|
| Rate for Payer: Healthscope Commercial |
$8.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.98
|
| Rate for Payer: PHP Commercial |
$7.91
|
| Rate for Payer: Priority Health SBD |
$5.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.05
|
| Rate for Payer: UHC Core |
$4.85
|
| Rate for Payer: UHC Exchange |
$3.66
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$279.06
|
|
|
Service Code
|
NDC 60687074421
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.67 |
| Max. Negotiated Rate |
$251.15 |
| Rate for Payer: Aetna Commercial |
$237.20
|
| Rate for Payer: Aetna Medicare |
$139.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.39
|
| Rate for Payer: BCBS Complete |
$111.62
|
| Rate for Payer: Cash Price |
$223.25
|
| Rate for Payer: Cofinity Advantage |
$195.34
|
| Rate for Payer: Cofinity Commercial |
$239.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.25
|
| Rate for Payer: Healthscope Commercial |
$251.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$223.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$209.29
|
| Rate for Payer: PHP Commercial |
$237.20
|
| Rate for Payer: Priority Health SBD |
$175.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$181.39
|
| Rate for Payer: UHC Core |
$145.39
|
| Rate for Payer: UHC Exchange |
$109.67
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
IP
|
$279.06
|
|
|
Service Code
|
NDC 60687074421
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.81 |
| Max. Negotiated Rate |
$251.15 |
| Rate for Payer: Aetna Commercial |
$237.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.39
|
| Rate for Payer: Cash Price |
$223.25
|
| Rate for Payer: Cofinity Advantage |
$195.34
|
| Rate for Payer: Cofinity Commercial |
$239.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.25
|
| Rate for Payer: Healthscope Commercial |
$251.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$209.29
|
| Rate for Payer: PHP Commercial |
$237.20
|
| Rate for Payer: Priority Health SBD |
$175.81
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
IP
|
$679.99
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$428.39 |
| Max. Negotiated Rate |
$611.99 |
| Rate for Payer: Aetna Commercial |
$577.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$441.99
|
| Rate for Payer: Cash Price |
$543.99
|
| Rate for Payer: Cofinity Advantage |
$475.99
|
| Rate for Payer: Cofinity Commercial |
$584.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$543.99
|
| Rate for Payer: Healthscope Commercial |
$611.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$577.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$509.99
|
| Rate for Payer: PHP Commercial |
$577.99
|
| Rate for Payer: Priority Health SBD |
$428.39
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
IP
|
$9.31
|
|
|
Service Code
|
NDC 60687074411
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$8.38 |
| Rate for Payer: Aetna Commercial |
$7.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.05
|
| Rate for Payer: Cash Price |
$7.45
|
| Rate for Payer: Cofinity Advantage |
$6.52
|
| Rate for Payer: Cofinity Commercial |
$8.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.45
|
| Rate for Payer: Healthscope Commercial |
$8.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.98
|
| Rate for Payer: PHP Commercial |
$7.91
|
| Rate for Payer: Priority Health SBD |
$5.87
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$306.71
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$193.23 |
| Max. Negotiated Rate |
$276.04 |
| Rate for Payer: Aetna Commercial |
$260.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.36
|
| Rate for Payer: Cash Price |
$245.37
|
| Rate for Payer: Cofinity Advantage |
$214.70
|
| Rate for Payer: Cofinity Commercial |
$263.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.37
|
| Rate for Payer: Healthscope Commercial |
$276.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.03
|
| Rate for Payer: PHP Commercial |
$260.70
|
| Rate for Payer: Priority Health SBD |
$193.23
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$224.79
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$202.31 |
| Rate for Payer: Aetna Commercial |
$191.07
|
| Rate for Payer: Aetna Commercial |
$260.70
|
| Rate for Payer: Aetna Commercial |
$162.14
|
| Rate for Payer: Aetna Medicare |
$153.35
|
| Rate for Payer: Aetna Medicare |
$112.39
|
| Rate for Payer: Aetna Medicare |
$95.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.99
|
| Rate for Payer: BCBS Complete |
$122.68
|
| Rate for Payer: BCBS Complete |
$76.30
|
| Rate for Payer: BCBS Complete |
$89.92
|
| Rate for Payer: BCBS Trust/PPO |
$10.15
|
| Rate for Payer: BCBS Trust/PPO |
$10.15
|
| Rate for Payer: BCBS Trust/PPO |
$10.15
|
| Rate for Payer: BCN Commercial |
$10.15
|
| Rate for Payer: BCN Commercial |
$10.15
|
| Rate for Payer: BCN Commercial |
$10.15
|
| Rate for Payer: Cash Price |
$179.83
|
| Rate for Payer: Cash Price |
$152.60
|
| Rate for Payer: Cash Price |
$245.37
|
| Rate for Payer: Cash Price |
$179.83
|
| Rate for Payer: Cash Price |
$245.37
|
| Rate for Payer: Cash Price |
$152.60
|
| Rate for Payer: Cofinity Advantage |
$157.35
|
| Rate for Payer: Cofinity Advantage |
$133.53
|
| Rate for Payer: Cofinity Advantage |
$214.70
|
| Rate for Payer: Cofinity Commercial |
$164.04
|
| Rate for Payer: Cofinity Commercial |
$193.32
|
| Rate for Payer: Cofinity Commercial |
$263.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.37
|
| Rate for Payer: Healthscope Commercial |
$276.04
|
| Rate for Payer: Healthscope Commercial |
$202.31
|
| Rate for Payer: Healthscope Commercial |
$171.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$245.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$152.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$179.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$162.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$143.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$168.59
|
| Rate for Payer: PHP Commercial |
$191.07
|
| Rate for Payer: PHP Commercial |
$260.70
|
| Rate for Payer: PHP Commercial |
$162.14
|
| Rate for Payer: Priority Health SBD |
$193.23
|
| Rate for Payer: Priority Health SBD |
$141.62
|
| Rate for Payer: Priority Health SBD |
$120.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.80
|
| Rate for Payer: UHC Core |
$6.80
|
| Rate for Payer: UHC Core |
$6.80
|
| Rate for Payer: UHC Core |
$6.80
|
| Rate for Payer: UHC Exchange |
$6.80
|
| Rate for Payer: UHC Exchange |
$6.80
|
| Rate for Payer: UHC Exchange |
$6.80
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$6,744.00
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
171111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,248.72 |
| Max. Negotiated Rate |
$6,069.60 |
| Rate for Payer: Aetna Commercial |
$5,732.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,383.60
|
| Rate for Payer: Cash Price |
$5,395.20
|
| Rate for Payer: Cofinity Advantage |
$4,720.80
|
| Rate for Payer: Cofinity Commercial |
$5,799.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,395.20
|
| Rate for Payer: Healthscope Commercial |
$6,069.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,732.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,058.00
|
| Rate for Payer: PHP Commercial |
$5,732.40
|
| Rate for Payer: Priority Health SBD |
$4,248.72
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$6,744.00
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
171111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$6,069.60 |
| Rate for Payer: Aetna Commercial |
$5,732.40
|
| Rate for Payer: Aetna Medicare |
$15.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,383.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18.75
|
| Rate for Payer: BCBS Complete |
$8.24
|
| Rate for Payer: BCBS MAPPO |
$15.00
|
| Rate for Payer: BCBS Trust/PPO |
$39.10
|
| Rate for Payer: BCN Commercial |
$39.10
|
| Rate for Payer: BCN Medicare Advantage |
$15.00
|
| Rate for Payer: Cash Price |
$5,395.20
|
| Rate for Payer: Cash Price |
$5,395.20
|
| Rate for Payer: Cofinity Advantage |
$4,720.80
|
| Rate for Payer: Cofinity Commercial |
$5,799.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,395.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.00
|
| Rate for Payer: Healthscope Commercial |
$6,069.60
|
| Rate for Payer: Mclaren Medicaid |
$7.84
|
| Rate for Payer: Mclaren Medicare |
$15.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15.75
|
| Rate for Payer: Meridian Medicaid |
$15.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.25
|
| Rate for Payer: Molina Medicare/Medicaid |
$16.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,732.40
|
| Rate for Payer: Nomi Health Commercial |
$45.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,058.00
|
| Rate for Payer: PACE Medicare |
$14.25
|
| Rate for Payer: PACE SWMI |
$15.00
|
| Rate for Payer: PHP Commercial |
$5,732.40
|
| Rate for Payer: PHP Medicare Advantage |
$15.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$49.25
|
| Rate for Payer: Priority Health Medicare |
$15.00
|
| Rate for Payer: Priority Health SBD |
$4,248.72
|
| Rate for Payer: Priority Health Tiered Network |
$39.40
|
| Rate for Payer: Railroad Medicare Medicare |
$15.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.72
|
| Rate for Payer: UHC Core |
$25.72
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$15.00
|
| Rate for Payer: UHC Exchange |
$25.72
|
| Rate for Payer: UHC Medicaid |
$7.84
|
| Rate for Payer: UHCCP Medicaid |
$7.84
|
| Rate for Payer: VA VA |
$15.00
|
|
|
DALFAMPRIDINE ER 10 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
OP
|
$9,960.03
|
|
|
Service Code
|
NDC 10144042760
|
| Hospital Charge Code |
100796
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,914.29 |
| Max. Negotiated Rate |
$8,964.03 |
| Rate for Payer: Aetna Commercial |
$8,466.03
|
| Rate for Payer: Aetna Medicare |
$4,980.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,474.02
|
| Rate for Payer: BCBS Complete |
$3,984.01
|
| Rate for Payer: Cash Price |
$7,968.02
|
| Rate for Payer: Cofinity Advantage |
$6,972.02
|
| Rate for Payer: Cofinity Commercial |
$8,565.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,968.02
|
| Rate for Payer: Healthscope Commercial |
$8,964.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,968.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,466.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7,470.02
|
| Rate for Payer: PHP Commercial |
$8,466.03
|
| Rate for Payer: Priority Health SBD |
$6,274.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6,474.02
|
| Rate for Payer: UHC Core |
$5,189.18
|
| Rate for Payer: UHC Exchange |
$3,914.29
|
|
|
DALFAMPRIDINE ER 10 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$9,960.03
|
|
|
Service Code
|
NDC 10144042760
|
| Hospital Charge Code |
100796
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,274.82 |
| Max. Negotiated Rate |
$8,964.03 |
| Rate for Payer: Aetna Commercial |
$8,466.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,474.02
|
| Rate for Payer: Cash Price |
$7,968.02
|
| Rate for Payer: Cofinity Advantage |
$6,972.02
|
| Rate for Payer: Cofinity Commercial |
$8,565.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,968.02
|
| Rate for Payer: Healthscope Commercial |
$8,964.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,466.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7,470.02
|
| Rate for Payer: PHP Commercial |
$8,466.03
|
| Rate for Payer: Priority Health SBD |
$6,274.82
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$218.92
|
|
|
Service Code
|
NDC 27505000367
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.04 |
| Max. Negotiated Rate |
$197.03 |
| Rate for Payer: Aetna Commercial |
$186.08
|
| Rate for Payer: Aetna Medicare |
$109.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.30
|
| Rate for Payer: BCBS Complete |
$87.57
|
| Rate for Payer: Cash Price |
$175.14
|
| Rate for Payer: Cofinity Advantage |
$153.24
|
| Rate for Payer: Cofinity Commercial |
$188.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.14
|
| Rate for Payer: Healthscope Commercial |
$197.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$175.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.19
|
| Rate for Payer: PHP Commercial |
$186.08
|
| Rate for Payer: Priority Health SBD |
$137.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.30
|
| Rate for Payer: UHC Core |
$114.06
|
| Rate for Payer: UHC Exchange |
$86.04
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$218.92
|
|
|
Service Code
|
NDC 78670000367
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.04 |
| Max. Negotiated Rate |
$197.03 |
| Rate for Payer: Aetna Commercial |
$186.08
|
| Rate for Payer: Aetna Medicare |
$109.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.30
|
| Rate for Payer: BCBS Complete |
$87.57
|
| Rate for Payer: Cash Price |
$175.14
|
| Rate for Payer: Cofinity Advantage |
$153.24
|
| Rate for Payer: Cofinity Commercial |
$188.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.14
|
| Rate for Payer: Healthscope Commercial |
$197.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$175.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.19
|
| Rate for Payer: PHP Commercial |
$186.08
|
| Rate for Payer: Priority Health SBD |
$137.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.30
|
| Rate for Payer: UHC Core |
$114.06
|
| Rate for Payer: UHC Exchange |
$86.04
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$218.92
|
|
|
Service Code
|
NDC 78670000367
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.92 |
| Max. Negotiated Rate |
$197.03 |
| Rate for Payer: Aetna Commercial |
$186.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.30
|
| Rate for Payer: Cash Price |
$175.14
|
| Rate for Payer: Cofinity Advantage |
$153.24
|
| Rate for Payer: Cofinity Commercial |
$188.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.14
|
| Rate for Payer: Healthscope Commercial |
$197.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.19
|
| Rate for Payer: PHP Commercial |
$186.08
|
| Rate for Payer: Priority Health SBD |
$137.92
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$218.92
|
|
|
Service Code
|
NDC 27505000367
|
| Hospital Charge Code |
9716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.92 |
| Max. Negotiated Rate |
$197.03 |
| Rate for Payer: Aetna Commercial |
$186.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.30
|
| Rate for Payer: Cash Price |
$175.14
|
| Rate for Payer: Cofinity Advantage |
$153.24
|
| Rate for Payer: Cofinity Commercial |
$188.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.14
|
| Rate for Payer: Healthscope Commercial |
$197.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.19
|
| Rate for Payer: PHP Commercial |
$186.08
|
| Rate for Payer: Priority Health SBD |
$137.92
|
|
|
DANTROLENE IVPB
|
Facility
|
IP
|
$218.92
|
|
|
Service Code
|
NDC 27505000367
|
| Hospital Charge Code |
400129
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.92 |
| Max. Negotiated Rate |
$197.03 |
| Rate for Payer: Aetna Commercial |
$186.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.30
|
| Rate for Payer: Cash Price |
$175.14
|
| Rate for Payer: Cofinity Advantage |
$153.24
|
| Rate for Payer: Cofinity Commercial |
$188.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.14
|
| Rate for Payer: Healthscope Commercial |
$197.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.19
|
| Rate for Payer: PHP Commercial |
$186.08
|
| Rate for Payer: Priority Health SBD |
$137.92
|
|
|
DANTROLENE IVPB
|
Facility
|
OP
|
$218.92
|
|
|
Service Code
|
NDC 27505000367
|
| Hospital Charge Code |
400129
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.04 |
| Max. Negotiated Rate |
$197.03 |
| Rate for Payer: Aetna Commercial |
$186.08
|
| Rate for Payer: Aetna Medicare |
$109.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.30
|
| Rate for Payer: BCBS Complete |
$87.57
|
| Rate for Payer: Cash Price |
$175.14
|
| Rate for Payer: Cofinity Advantage |
$153.24
|
| Rate for Payer: Cofinity Commercial |
$188.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.14
|
| Rate for Payer: Healthscope Commercial |
$197.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$175.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.19
|
| Rate for Payer: PHP Commercial |
$186.08
|
| Rate for Payer: Priority Health SBD |
$137.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.30
|
| Rate for Payer: UHC Core |
$114.06
|
| Rate for Payer: UHC Exchange |
$86.04
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET
|
Facility
|
OP
|
$1,400.16
|
|
|
Service Code
|
NDC 00310621039
|
| Hospital Charge Code |
169524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$550.26 |
| Max. Negotiated Rate |
$1,260.14 |
| Rate for Payer: Aetna Commercial |
$1,190.14
|
| Rate for Payer: Aetna Medicare |
$700.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$910.10
|
| Rate for Payer: BCBS Complete |
$560.06
|
| Rate for Payer: Cash Price |
$1,120.13
|
| Rate for Payer: Cofinity Advantage |
$980.11
|
| Rate for Payer: Cofinity Commercial |
$1,204.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,120.13
|
| Rate for Payer: Healthscope Commercial |
$1,260.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,120.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,190.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,050.12
|
| Rate for Payer: PHP Commercial |
$1,190.14
|
| Rate for Payer: Priority Health SBD |
$882.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$910.10
|
| Rate for Payer: UHC Core |
$729.48
|
| Rate for Payer: UHC Exchange |
$550.26
|
|
