|
CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;
|
Facility
|
OP
|
$5,623.80
|
|
|
Service Code
|
CPT 52005
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,070.86 |
| Max. Negotiated Rate |
$5,623.80 |
| Rate for Payer: Aetna Medicare |
$2,077.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,497.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,497.34
|
| Rate for Payer: BCBS Complete |
$1,124.40
|
| Rate for Payer: BCBS MAPPO |
$1,997.87
|
| Rate for Payer: BCN Medicare Advantage |
$1,997.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,997.87
|
| Rate for Payer: Mclaren Medicaid |
$1,070.86
|
| Rate for Payer: Mclaren Medicare |
$1,997.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,097.76
|
| Rate for Payer: Meridian Medicaid |
$1,124.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,297.55
|
| Rate for Payer: PACE Medicare |
$1,897.98
|
| Rate for Payer: PACE SWMI |
$1,997.87
|
| Rate for Payer: PHP Medicare Advantage |
$1,997.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,070.86
|
| Rate for Payer: Priority Health Medicare |
$1,997.87
|
| Rate for Payer: Railroad Medicare Medicare |
$1,997.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,623.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,997.87
|
| Rate for Payer: UHC Medicare Advantage |
$1,997.87
|
| Rate for Payer: UHCCP Medicaid |
$1,124.80
|
| Rate for Payer: VA VA |
$1,997.87
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 52351
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.95 |
| Max. Negotiated Rate |
$9,468.51 |
| Rate for Payer: Aetna Medicare |
$3,498.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,204.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,204.64
|
| Rate for Payer: BCBS Complete |
$1,893.10
|
| Rate for Payer: BCBS MAPPO |
$3,363.71
|
| Rate for Payer: BCN Medicare Advantage |
$3,363.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,363.71
|
| Rate for Payer: Mclaren Medicaid |
$1,802.95
|
| Rate for Payer: Mclaren Medicare |
$3,363.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,531.90
|
| Rate for Payer: Meridian Medicaid |
$1,893.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,868.27
|
| Rate for Payer: PACE Medicare |
$3,195.52
|
| Rate for Payer: PACE SWMI |
$3,363.71
|
| Rate for Payer: PHP Medicare Advantage |
$3,363.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,802.95
|
| Rate for Payer: Priority Health Medicare |
$3,363.71
|
| Rate for Payer: Railroad Medicare Medicare |
$3,363.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,468.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,363.71
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,893.77
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION
|
Facility
|
OP
|
$13,956.13
|
|
|
Service Code
|
CPT 52354
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,657.46 |
| Max. Negotiated Rate |
$13,956.13 |
| Rate for Payer: Aetna Medicare |
$5,156.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,197.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,197.44
|
| Rate for Payer: BCBS Complete |
$2,790.33
|
| Rate for Payer: BCBS MAPPO |
$4,957.95
|
| Rate for Payer: BCN Medicare Advantage |
$4,957.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,957.95
|
| Rate for Payer: Mclaren Medicaid |
$2,657.46
|
| Rate for Payer: Mclaren Medicare |
$4,957.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,205.85
|
| Rate for Payer: Meridian Medicaid |
$2,790.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,701.64
|
| Rate for Payer: PACE Medicare |
$4,710.05
|
| Rate for Payer: PACE SWMI |
$4,957.95
|
| Rate for Payer: PHP Medicare Advantage |
$4,957.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,657.46
|
| Rate for Payer: Priority Health Medicare |
$4,957.95
|
| Rate for Payer: Railroad Medicare Medicare |
$4,957.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,956.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,957.95
|
| Rate for Payer: UHC Medicare Advantage |
$4,957.95
|
| Rate for Payer: UHCCP Medicaid |
$2,791.33
|
| Rate for Payer: VA VA |
$4,957.95
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)
|
Facility
|
OP
|
$13,956.13
|
|
|
Service Code
|
CPT 52356
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,657.46 |
| Max. Negotiated Rate |
$13,956.13 |
| Rate for Payer: Aetna Medicare |
$5,156.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,197.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,197.44
|
| Rate for Payer: BCBS Complete |
$2,790.33
|
| Rate for Payer: BCBS MAPPO |
$4,957.95
|
| Rate for Payer: BCN Medicare Advantage |
$4,957.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,957.95
|
| Rate for Payer: Mclaren Medicaid |
$2,657.46
|
| Rate for Payer: Mclaren Medicare |
$4,957.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,205.85
|
| Rate for Payer: Meridian Medicaid |
$2,790.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,701.64
|
| Rate for Payer: PACE Medicare |
$4,710.05
|
| Rate for Payer: PACE SWMI |
$4,957.95
|
| Rate for Payer: PHP Medicare Advantage |
$4,957.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,657.46
|
| Rate for Payer: Priority Health Medicare |
$4,957.95
|
| Rate for Payer: Railroad Medicare Medicare |
$4,957.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,956.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,957.95
|
| Rate for Payer: UHC Medicare Advantage |
$4,957.95
|
| Rate for Payer: UHCCP Medicaid |
$2,791.33
|
| Rate for Payer: VA VA |
$4,957.95
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)
|
Facility
|
OP
|
$13,956.13
|
|
|
Service Code
|
CPT 52353
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,657.46 |
| Max. Negotiated Rate |
$13,956.13 |
| Rate for Payer: Aetna Medicare |
$5,156.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,197.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,197.44
|
| Rate for Payer: BCBS Complete |
$2,790.33
|
| Rate for Payer: BCBS MAPPO |
$4,957.95
|
| Rate for Payer: BCN Medicare Advantage |
$4,957.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,957.95
|
| Rate for Payer: Mclaren Medicaid |
$2,657.46
|
| Rate for Payer: Mclaren Medicare |
$4,957.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,205.85
|
| Rate for Payer: Meridian Medicaid |
$2,790.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,701.64
|
| Rate for Payer: PACE Medicare |
$4,710.05
|
| Rate for Payer: PACE SWMI |
$4,957.95
|
| Rate for Payer: PHP Medicare Advantage |
$4,957.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,657.46
|
| Rate for Payer: Priority Health Medicare |
$4,957.95
|
| Rate for Payer: Railroad Medicare Medicare |
$4,957.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,956.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,957.95
|
| Rate for Payer: UHC Medicare Advantage |
$4,957.95
|
| Rate for Payer: UHCCP Medicaid |
$2,791.33
|
| Rate for Payer: VA VA |
$4,957.95
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 52352
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.95 |
| Max. Negotiated Rate |
$9,468.51 |
| Rate for Payer: Aetna Medicare |
$3,498.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,204.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,204.64
|
| Rate for Payer: BCBS Complete |
$1,893.10
|
| Rate for Payer: BCBS MAPPO |
$3,363.71
|
| Rate for Payer: BCN Medicare Advantage |
$3,363.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,363.71
|
| Rate for Payer: Mclaren Medicaid |
$1,802.95
|
| Rate for Payer: Mclaren Medicare |
$3,363.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,531.90
|
| Rate for Payer: Meridian Medicaid |
$1,893.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,868.27
|
| Rate for Payer: PACE Medicare |
$3,195.52
|
| Rate for Payer: PACE SWMI |
$3,363.71
|
| Rate for Payer: PHP Medicare Advantage |
$3,363.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,802.95
|
| Rate for Payer: Priority Health Medicare |
$3,363.71
|
| Rate for Payer: Railroad Medicare Medicare |
$3,363.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,468.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,363.71
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,893.77
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR
|
Facility
|
OP
|
$13,956.13
|
|
|
Service Code
|
CPT 52355
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,657.46 |
| Max. Negotiated Rate |
$13,956.13 |
| Rate for Payer: Aetna Medicare |
$5,156.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,197.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,197.44
|
| Rate for Payer: BCBS Complete |
$2,790.33
|
| Rate for Payer: BCBS MAPPO |
$4,957.95
|
| Rate for Payer: BCN Medicare Advantage |
$4,957.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,957.95
|
| Rate for Payer: Mclaren Medicaid |
$2,657.46
|
| Rate for Payer: Mclaren Medicare |
$4,957.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,205.85
|
| Rate for Payer: Meridian Medicaid |
$2,790.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,701.64
|
| Rate for Payer: PACE Medicare |
$4,710.05
|
| Rate for Payer: PACE SWMI |
$4,957.95
|
| Rate for Payer: PHP Medicare Advantage |
$4,957.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,657.46
|
| Rate for Payer: Priority Health Medicare |
$4,957.95
|
| Rate for Payer: Railroad Medicare Medicare |
$4,957.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,956.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,957.95
|
| Rate for Payer: UHC Medicare Advantage |
$4,957.95
|
| Rate for Payer: UHCCP Medicaid |
$2,791.33
|
| Rate for Payer: VA VA |
$4,957.95
|
|
|
CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 52344
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.95 |
| Max. Negotiated Rate |
$9,468.51 |
| Rate for Payer: Aetna Medicare |
$3,498.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,204.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,204.64
|
| Rate for Payer: BCBS Complete |
$1,893.10
|
| Rate for Payer: BCBS MAPPO |
$3,363.71
|
| Rate for Payer: BCN Medicare Advantage |
$3,363.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,363.71
|
| Rate for Payer: Mclaren Medicaid |
$1,802.95
|
| Rate for Payer: Mclaren Medicare |
$3,363.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,531.90
|
| Rate for Payer: Meridian Medicaid |
$1,893.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,868.27
|
| Rate for Payer: PACE Medicare |
$3,195.52
|
| Rate for Payer: PACE SWMI |
$3,363.71
|
| Rate for Payer: PHP Medicare Advantage |
$3,363.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,802.95
|
| Rate for Payer: Priority Health Medicare |
$3,363.71
|
| Rate for Payer: Railroad Medicare Medicare |
$3,363.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,468.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,363.71
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,893.77
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
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 Commercial |
$148.57
|
| Rate for Payer: Cofinity Commercial |
$182.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.57
|
| 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: PHP Commercial |
$180.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.96
|
| Rate for Payer: Priority Health SBD |
$133.72
|
|
|
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 |
$84.90 |
| 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: Cash Price |
$169.80
|
| Rate for Payer: Cofinity Commercial |
$148.57
|
| Rate for Payer: Cofinity Commercial |
$182.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.57
|
| 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: PHP Commercial |
$180.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.96
|
| Rate for Payer: Priority Health SBD |
$133.72
|
|
|
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 Commercial |
$475.99
|
| Rate for Payer: Cofinity Commercial |
$584.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$475.99
|
| 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: PHP Commercial |
$577.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$441.99
|
| Rate for Payer: Priority Health SBD |
$428.39
|
|
|
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 Commercial |
$195.34
|
| Rate for Payer: Cofinity Commercial |
$239.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$195.34
|
| 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: PHP Commercial |
$237.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.39
|
| Rate for Payer: Priority Health SBD |
$175.81
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$9.31
|
|
|
Service Code
|
NDC 60687074411
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| 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 Commercial |
$6.52
|
| Rate for Payer: Cofinity Commercial |
$8.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.52
|
| 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: PHP Commercial |
$7.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.05
|
| Rate for Payer: Priority Health SBD |
$5.87
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$576.00
|
|
|
Service Code
|
NDC 31722062160
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$489.60
|
| Rate for Payer: Aetna Medicare |
$288.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$374.40
|
| Rate for Payer: BCBS Complete |
$230.40
|
| Rate for Payer: Cash Price |
$460.80
|
| Rate for Payer: Cofinity Commercial |
$403.20
|
| Rate for Payer: Cofinity Commercial |
$495.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$403.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$460.80
|
| Rate for Payer: Healthscope Commercial |
$518.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$489.60
|
| Rate for Payer: PHP Commercial |
$489.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$374.40
|
| Rate for Payer: Priority Health SBD |
$362.88
|
|
|
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 Commercial |
$6.52
|
| Rate for Payer: Cofinity Commercial |
$8.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.52
|
| 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: PHP Commercial |
$7.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.05
|
| Rate for Payer: Priority Health SBD |
$5.87
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$279.06
|
|
|
Service Code
|
NDC 60687074421
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.62 |
| 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 Commercial |
$195.34
|
| Rate for Payer: Cofinity Commercial |
$239.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$195.34
|
| 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: PHP Commercial |
$237.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.39
|
| Rate for Payer: Priority Health SBD |
$175.81
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
OP
|
$679.99
|
|
|
Service Code
|
NDC 00597035556
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$272.00 |
| 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 Commercial |
$475.99
|
| Rate for Payer: Cofinity Commercial |
$584.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$475.99
|
| 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: PHP Commercial |
$577.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$441.99
|
| Rate for Payer: Priority Health SBD |
$428.39
|
|
|
DABIGATRAN ETEXILATE 75 MG CAPSULE
|
Facility
|
IP
|
$576.00
|
|
|
Service Code
|
NDC 31722062160
|
| Hospital Charge Code |
106490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$362.88 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$489.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$374.40
|
| Rate for Payer: Cash Price |
$460.80
|
| Rate for Payer: Cofinity Commercial |
$403.20
|
| Rate for Payer: Cofinity Commercial |
$495.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$403.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$460.80
|
| Rate for Payer: Healthscope Commercial |
$518.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$489.60
|
| Rate for Payer: PHP Commercial |
$489.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$374.40
|
| Rate for Payer: Priority Health SBD |
$362.88
|
|
|
DACARBAZINE 200 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$306.71
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$276.04 |
| Rate for Payer: Aetna Commercial |
$260.70
|
| Rate for Payer: Aetna Commercial |
$162.14
|
| Rate for Payer: Aetna Commercial |
$56.83
|
| Rate for Payer: Aetna Medicare |
$95.38
|
| Rate for Payer: Aetna Medicare |
$33.43
|
| Rate for Payer: Aetna Medicare |
$153.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.36
|
| Rate for Payer: BCBS Complete |
$76.30
|
| Rate for Payer: BCBS Complete |
$122.68
|
| Rate for Payer: BCBS Complete |
$26.74
|
| Rate for Payer: Cash Price |
$152.60
|
| Rate for Payer: Cash Price |
$245.37
|
| Rate for Payer: Cash Price |
$53.49
|
| Rate for Payer: Cofinity Commercial |
$46.80
|
| Rate for Payer: Cofinity Commercial |
$57.50
|
| Rate for Payer: Cofinity Commercial |
$214.70
|
| Rate for Payer: Cofinity Commercial |
$263.77
|
| Rate for Payer: Cofinity Commercial |
$164.04
|
| Rate for Payer: Cofinity Commercial |
$133.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$214.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$133.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$245.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.49
|
| Rate for Payer: Healthscope Commercial |
$171.68
|
| Rate for Payer: Healthscope Commercial |
$276.04
|
| Rate for Payer: Healthscope Commercial |
$60.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$162.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.70
|
| Rate for Payer: PHP Commercial |
$162.14
|
| Rate for Payer: PHP Commercial |
$260.70
|
| Rate for Payer: PHP Commercial |
$56.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.36
|
| Rate for Payer: Priority Health SBD |
$193.23
|
| Rate for Payer: Priority Health SBD |
$120.17
|
| Rate for Payer: Priority Health SBD |
$42.12
|
|
|
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 Commercial |
$214.70
|
| Rate for Payer: Cofinity Commercial |
$263.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$214.70
|
| 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: PHP Commercial |
$260.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.36
|
| Rate for Payer: Priority Health SBD |
$193.23
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,976.00
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
171111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$2,678.40 |
| Rate for Payer: Aetna Commercial |
$2,529.60
|
| Rate for Payer: Aetna Medicare |
$16.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,934.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.51
|
| Rate for Payer: BCBS Complete |
$8.79
|
| Rate for Payer: BCBS MAPPO |
$15.61
|
| Rate for Payer: BCN Medicare Advantage |
$15.61
|
| Rate for Payer: Cash Price |
$2,380.80
|
| Rate for Payer: Cash Price |
$2,380.80
|
| Rate for Payer: Cofinity Commercial |
$2,559.36
|
| Rate for Payer: Cofinity Commercial |
$2,083.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,083.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,380.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.61
|
| Rate for Payer: Healthscope Commercial |
$2,678.40
|
| Rate for Payer: Mclaren Medicaid |
$8.37
|
| Rate for Payer: Mclaren Medicare |
$15.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.39
|
| Rate for Payer: Meridian Medicaid |
$8.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,529.60
|
| Rate for Payer: PACE Medicare |
$14.83
|
| Rate for Payer: PACE SWMI |
$15.61
|
| Rate for Payer: PHP Commercial |
$2,529.60
|
| Rate for Payer: PHP Medicare Advantage |
$15.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,934.40
|
| Rate for Payer: Priority Health Medicare |
$15.61
|
| Rate for Payer: Priority Health SBD |
$1,874.88
|
| Rate for Payer: Railroad Medicare Medicare |
$15.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$43.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.61
|
| Rate for Payer: UHC Medicare Advantage |
$15.61
|
| Rate for Payer: UHCCP Medicaid |
$8.79
|
| Rate for Payer: VA VA |
$15.61
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,976.00
|
|
|
Service Code
|
HCPCS J0875
|
| Hospital Charge Code |
171111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,874.88 |
| Max. Negotiated Rate |
$2,678.40 |
| Rate for Payer: Aetna Commercial |
$2,529.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,934.40
|
| Rate for Payer: Cash Price |
$2,380.80
|
| Rate for Payer: Cofinity Commercial |
$2,083.20
|
| Rate for Payer: Cofinity Commercial |
$2,559.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,083.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,380.80
|
| Rate for Payer: Healthscope Commercial |
$2,678.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,529.60
|
| Rate for Payer: PHP Commercial |
$2,529.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,934.40
|
| Rate for Payer: Priority Health SBD |
$1,874.88
|
|
|
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 |
$3,984.01 |
| 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 Commercial |
$6,972.02
|
| Rate for Payer: Cofinity Commercial |
$8,565.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,972.02
|
| 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: PHP Commercial |
$8,466.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,474.02
|
| Rate for Payer: Priority Health SBD |
$6,274.82
|
|
|
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 Commercial |
$6,972.02
|
| Rate for Payer: Cofinity Commercial |
$8,565.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,972.02
|
| 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: PHP Commercial |
$8,466.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,474.02
|
| 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 |
$87.57 |
| 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 Commercial |
$153.24
|
| Rate for Payer: Cofinity Commercial |
$188.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$153.24
|
| 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: PHP Commercial |
$186.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.30
|
| Rate for Payer: Priority Health SBD |
$137.92
|
|
