|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 50268030411
|
| Hospital Charge Code |
10012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Aetna Commercial |
$2.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.55
|
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: Cofinity Advantage |
$1.67
|
| Rate for Payer: Cofinity Commercial |
$2.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.90
|
| Rate for Payer: Healthscope Commercial |
$2.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.78
|
| Rate for Payer: PHP Commercial |
$2.02
|
| Rate for Payer: Priority Health SBD |
$1.50
|
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 61442012201
|
| Hospital Charge Code |
10012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.78 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.13
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Advantage |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$200.93
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health SBD |
$168.78
|
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$118.75
|
|
|
Service Code
|
NDC 50268030415
|
| Hospital Charge Code |
10012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.81 |
| Max. Negotiated Rate |
$106.88 |
| Rate for Payer: Aetna Commercial |
$100.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.19
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cofinity Advantage |
$83.12
|
| Rate for Payer: Cofinity Commercial |
$102.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.00
|
| Rate for Payer: Healthscope Commercial |
$106.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.06
|
| Rate for Payer: PHP Commercial |
$100.94
|
| Rate for Payer: Priority Health SBD |
$74.81
|
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
OP
|
$118.75
|
|
|
Service Code
|
NDC 50268030415
|
| Hospital Charge Code |
10012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.67 |
| Max. Negotiated Rate |
$106.88 |
| Rate for Payer: Aetna Commercial |
$100.94
|
| Rate for Payer: Aetna Medicare |
$59.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.19
|
| Rate for Payer: BCBS Complete |
$47.50
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cofinity Advantage |
$83.12
|
| Rate for Payer: Cofinity Commercial |
$102.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.00
|
| Rate for Payer: Healthscope Commercial |
$106.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.06
|
| Rate for Payer: PHP Commercial |
$100.94
|
| Rate for Payer: Priority Health SBD |
$74.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.19
|
| Rate for Payer: UHC Core |
$61.87
|
| Rate for Payer: UHC Exchange |
$46.67
|
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$9,665.51
|
|
|
Service Code
|
NDC 00187444010
|
| Hospital Charge Code |
10012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,089.27 |
| Max. Negotiated Rate |
$8,698.96 |
| Rate for Payer: Aetna Commercial |
$8,215.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,282.58
|
| Rate for Payer: Cash Price |
$7,732.41
|
| Rate for Payer: Cofinity Advantage |
$6,765.86
|
| Rate for Payer: Cofinity Commercial |
$8,312.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,732.41
|
| Rate for Payer: Healthscope Commercial |
$8,698.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,215.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7,249.13
|
| Rate for Payer: PHP Commercial |
$8,215.68
|
| Rate for Payer: Priority Health SBD |
$6,089.27
|
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
IP
|
$197.60
|
|
|
Service Code
|
NDC 00172572960
|
| Hospital Charge Code |
10012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.49 |
| Max. Negotiated Rate |
$177.84 |
| Rate for Payer: Aetna Commercial |
$167.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.44
|
| Rate for Payer: Cash Price |
$158.08
|
| Rate for Payer: Cofinity Advantage |
$138.32
|
| Rate for Payer: Cofinity Commercial |
$169.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.08
|
| Rate for Payer: Healthscope Commercial |
$177.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.20
|
| Rate for Payer: PHP Commercial |
$167.96
|
| Rate for Payer: Priority Health SBD |
$124.49
|
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
OP
|
$988.00
|
|
|
Service Code
|
NDC 00172572970
|
| Hospital Charge Code |
10012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$388.28 |
| Max. Negotiated Rate |
$889.20 |
| Rate for Payer: Aetna Commercial |
$839.80
|
| Rate for Payer: Aetna Medicare |
$494.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$642.20
|
| Rate for Payer: BCBS Complete |
$395.20
|
| Rate for Payer: Cash Price |
$790.40
|
| Rate for Payer: Cofinity Advantage |
$691.60
|
| Rate for Payer: Cofinity Commercial |
$849.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$790.40
|
| Rate for Payer: Healthscope Commercial |
$889.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$790.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$839.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$741.00
|
| Rate for Payer: PHP Commercial |
$839.80
|
| Rate for Payer: Priority Health SBD |
$622.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$642.20
|
| Rate for Payer: UHC Core |
$514.75
|
| Rate for Payer: UHC Exchange |
$388.28
|
|
|
FAMOTIDINE 40 MG TABLET
|
Facility
|
OP
|
$197.60
|
|
|
Service Code
|
NDC 00172572960
|
| Hospital Charge Code |
10012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.66 |
| Max. Negotiated Rate |
$177.84 |
| Rate for Payer: Aetna Commercial |
$167.96
|
| Rate for Payer: Aetna Medicare |
$98.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.44
|
| Rate for Payer: BCBS Complete |
$79.04
|
| Rate for Payer: Cash Price |
$158.08
|
| Rate for Payer: Cofinity Advantage |
$138.32
|
| Rate for Payer: Cofinity Commercial |
$169.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.08
|
| Rate for Payer: Healthscope Commercial |
$177.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$158.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.20
|
| Rate for Payer: PHP Commercial |
$167.96
|
| Rate for Payer: Priority Health SBD |
$124.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.44
|
| Rate for Payer: UHC Core |
$102.95
|
| Rate for Payer: UHC Exchange |
$77.66
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna Commercial |
$13.01
|
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Advantage |
$9.06
|
| Rate for Payer: Cofinity Advantage |
$10.71
|
| Rate for Payer: Cofinity Advantage |
$11.23
|
| Rate for Payer: Cofinity Advantage |
$8.44
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$10.85
|
| Rate for Payer: Healthscope Commercial |
$13.77
|
| Rate for Payer: Healthscope Commercial |
$11.65
|
| Rate for Payer: Healthscope Commercial |
$14.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.04
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.01
|
| Rate for Payer: Priority Health SBD |
$9.64
|
| Rate for Payer: Priority Health SBD |
$8.16
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: Priority Health SBD |
$7.59
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna Commercial |
$13.01
|
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna Medicare |
$6.47
|
| Rate for Payer: Aetna Medicare |
$8.03
|
| Rate for Payer: Aetna Medicare |
$7.65
|
| Rate for Payer: Aetna Medicare |
$6.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: BCBS Complete |
$6.42
|
| Rate for Payer: BCBS Complete |
$5.18
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: BCBS Complete |
$6.12
|
| Rate for Payer: BCBS Trust/PPO |
$0.02
|
| Rate for Payer: BCBS Trust/PPO |
$0.02
|
| Rate for Payer: BCBS Trust/PPO |
$0.02
|
| Rate for Payer: BCBS Trust/PPO |
$0.02
|
| Rate for Payer: BCN Commercial |
$0.02
|
| Rate for Payer: BCN Commercial |
$0.02
|
| Rate for Payer: BCN Commercial |
$0.02
|
| Rate for Payer: BCN Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Advantage |
$11.23
|
| Rate for Payer: Cofinity Advantage |
$8.44
|
| Rate for Payer: Cofinity Advantage |
$10.71
|
| Rate for Payer: Cofinity Advantage |
$9.06
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$13.77
|
| Rate for Payer: Healthscope Commercial |
$10.85
|
| Rate for Payer: Healthscope Commercial |
$14.45
|
| Rate for Payer: Healthscope Commercial |
$11.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.04
|
| Rate for Payer: PHP Commercial |
$13.01
|
| Rate for Payer: PHP Commercial |
$11.01
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health SBD |
$7.59
|
| Rate for Payer: Priority Health SBD |
$9.64
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: Priority Health SBD |
$8.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.02
|
| Rate for Payer: UHC Core |
$0.02
|
| Rate for Payer: UHC Core |
$0.02
|
| Rate for Payer: UHC Core |
$0.02
|
| Rate for Payer: UHC Core |
$0.02
|
| Rate for Payer: UHC Exchange |
$0.02
|
| Rate for Payer: UHC Exchange |
$0.02
|
| Rate for Payer: UHC Exchange |
$0.02
|
| Rate for Payer: UHC Exchange |
$0.02
|
|
|
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$14,551.15
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
192405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,167.22 |
| Max. Negotiated Rate |
$13,096.03 |
| Rate for Payer: Aetna Commercial |
$12,368.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,458.25
|
| Rate for Payer: Cash Price |
$11,640.92
|
| Rate for Payer: Cofinity Advantage |
$10,185.81
|
| Rate for Payer: Cofinity Commercial |
$12,513.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,640.92
|
| Rate for Payer: Healthscope Commercial |
$13,096.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,368.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10,913.36
|
| Rate for Payer: PHP Commercial |
$12,368.48
|
| Rate for Payer: Priority Health SBD |
$9,167.22
|
|
|
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$14,551.15
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
192405
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$13,096.03 |
| Rate for Payer: Aetna Commercial |
$12,368.48
|
| Rate for Payer: Aetna Medicare |
$32.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,458.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$39.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$39.08
|
| Rate for Payer: BCBS Complete |
$17.17
|
| Rate for Payer: BCBS MAPPO |
$31.26
|
| Rate for Payer: BCBS Trust/PPO |
$78.53
|
| Rate for Payer: BCN Commercial |
$78.53
|
| Rate for Payer: BCN Medicare Advantage |
$31.26
|
| Rate for Payer: Cash Price |
$11,640.92
|
| Rate for Payer: Cash Price |
$11,640.92
|
| Rate for Payer: Cofinity Advantage |
$10,185.81
|
| Rate for Payer: Cofinity Commercial |
$12,513.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11,640.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$31.26
|
| Rate for Payer: Healthscope Commercial |
$13,096.03
|
| Rate for Payer: Mclaren Medicaid |
$16.35
|
| Rate for Payer: Mclaren Medicare |
$31.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$32.82
|
| Rate for Payer: Meridian Medicaid |
$32.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.95
|
| Rate for Payer: Molina Medicare/Medicaid |
$34.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,368.48
|
| Rate for Payer: Nomi Health Commercial |
$93.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10,913.36
|
| Rate for Payer: PACE Medicare |
$29.70
|
| Rate for Payer: PACE SWMI |
$31.26
|
| Rate for Payer: PHP Commercial |
$12,368.48
|
| Rate for Payer: PHP Medicare Advantage |
$31.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$16.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$94.54
|
| Rate for Payer: Priority Health Medicare |
$31.26
|
| Rate for Payer: Priority Health SBD |
$9,167.22
|
| Rate for Payer: Priority Health Tiered Network |
$75.63
|
| Rate for Payer: Railroad Medicare Medicare |
$31.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.65
|
| Rate for Payer: UHC Core |
$51.65
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$31.26
|
| Rate for Payer: UHC Exchange |
$51.65
|
| Rate for Payer: UHC Medicaid |
$16.35
|
| Rate for Payer: UHCCP Medicaid |
$16.35
|
| Rate for Payer: VA VA |
$31.26
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
NDC 00338051909
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.30 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.00
|
| Rate for Payer: Aetna Medicare |
$50.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cofinity Advantage |
$70.00
|
| Rate for Payer: Cofinity Commercial |
$86.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.00
|
| Rate for Payer: Healthscope Commercial |
$90.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$80.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.00
|
| Rate for Payer: PHP Commercial |
$85.00
|
| Rate for Payer: Priority Health SBD |
$63.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.00
|
| Rate for Payer: UHC Core |
$52.10
|
| Rate for Payer: UHC Exchange |
$39.30
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
NDC 00338051909
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cofinity Advantage |
$70.00
|
| Rate for Payer: Cofinity Commercial |
$86.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.00
|
| Rate for Payer: Healthscope Commercial |
$90.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.00
|
| Rate for Payer: PHP Commercial |
$85.00
|
| Rate for Payer: Priority Health SBD |
$63.00
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
OP
|
$13.50
|
|
|
Service Code
|
NDC 00338954003
|
| Hospital Charge Code |
212074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$12.15 |
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Medicare |
$6.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.78
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cofinity Advantage |
$9.45
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.80
|
| Rate for Payer: Healthscope Commercial |
$12.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.12
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health SBD |
$8.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.78
|
| Rate for Payer: UHC Core |
$7.03
|
| Rate for Payer: UHC Exchange |
$5.31
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
IP
|
$13.50
|
|
|
Service Code
|
NDC 00338954003
|
| Hospital Charge Code |
212074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$12.15 |
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.78
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cofinity Advantage |
$9.45
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.80
|
| Rate for Payer: Healthscope Commercial |
$12.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.12
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health SBD |
$8.51
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 63323082074
|
| Hospital Charge Code |
179808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.43 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: Aetna Commercial |
$20.40
|
| Rate for Payer: Aetna Medicare |
$12.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.60
|
| Rate for Payer: BCBS Complete |
$9.60
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cofinity Advantage |
$16.80
|
| Rate for Payer: Cofinity Commercial |
$20.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.20
|
| Rate for Payer: Healthscope Commercial |
$21.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.00
|
| Rate for Payer: PHP Commercial |
$20.40
|
| Rate for Payer: Priority Health SBD |
$15.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.60
|
| Rate for Payer: UHC Core |
$12.50
|
| Rate for Payer: UHC Exchange |
$9.43
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 63323082074
|
| Hospital Charge Code |
179808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: Aetna Commercial |
$20.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.60
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cofinity Advantage |
$16.80
|
| Rate for Payer: Cofinity Commercial |
$20.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.20
|
| Rate for Payer: Healthscope Commercial |
$21.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.00
|
| Rate for Payer: PHP Commercial |
$20.40
|
| Rate for Payer: Priority Health SBD |
$15.12
|
|
|
FECAL MICROBIOTA PRODUCT
|
Facility
|
IP
|
$2,499.70
|
|
|
Service Code
|
NDC 09900001129
|
| Hospital Charge Code |
300149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,574.81 |
| Max. Negotiated Rate |
$2,249.73 |
| Rate for Payer: Aetna Commercial |
$2,124.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,624.81
|
| Rate for Payer: Cash Price |
$1,999.76
|
| Rate for Payer: Cofinity Advantage |
$1,749.79
|
| Rate for Payer: Cofinity Commercial |
$2,149.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,999.76
|
| Rate for Payer: Healthscope Commercial |
$2,249.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,124.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,874.78
|
| Rate for Payer: PHP Commercial |
$2,124.74
|
| Rate for Payer: Priority Health SBD |
$1,574.81
|
|
|
FECAL MICROBIOTA PRODUCT
|
Facility
|
OP
|
$2,499.70
|
|
|
Service Code
|
NDC 09900001129
|
| Hospital Charge Code |
300149
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$982.38 |
| Max. Negotiated Rate |
$2,249.73 |
| Rate for Payer: Aetna Commercial |
$2,124.74
|
| Rate for Payer: Aetna Medicare |
$1,249.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,624.81
|
| Rate for Payer: BCBS Complete |
$999.88
|
| Rate for Payer: Cash Price |
$1,999.76
|
| Rate for Payer: Cofinity Advantage |
$1,749.79
|
| Rate for Payer: Cofinity Commercial |
$2,149.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,999.76
|
| Rate for Payer: Healthscope Commercial |
$2,249.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,999.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,124.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,874.78
|
| Rate for Payer: PHP Commercial |
$2,124.74
|
| Rate for Payer: Priority Health SBD |
$1,574.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,624.81
|
| Rate for Payer: UHC Core |
$1,302.34
|
| Rate for Payer: UHC Exchange |
$982.38
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$8,872.39
|
|
|
Service Code
|
APR-DRG 5314
|
| Min. Negotiated Rate |
$8,449.90 |
| Max. Negotiated Rate |
$8,872.39 |
| Rate for Payer: BCBS Complete |
$8,872.39
|
| Rate for Payer: Mclaren Medicaid |
$8,449.90
|
| Rate for Payer: Meridian Medicaid |
$8,872.39
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,449.90
|
| Rate for Payer: UHC Medicaid |
$8,449.90
|
| Rate for Payer: UHCCP Medicaid |
$8,449.90
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$3,103.85
|
|
|
Service Code
|
APR-DRG 5311
|
| Min. Negotiated Rate |
$2,956.04 |
| Max. Negotiated Rate |
$3,103.85 |
| Rate for Payer: BCBS Complete |
$3,103.85
|
| Rate for Payer: Mclaren Medicaid |
$2,956.04
|
| Rate for Payer: Meridian Medicaid |
$3,103.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,956.04
|
| Rate for Payer: UHC Medicaid |
$2,956.04
|
| Rate for Payer: UHCCP Medicaid |
$2,956.04
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$4,200.00
|
|
|
Service Code
|
APR-DRG 5312
|
| Min. Negotiated Rate |
$4,000.00 |
| Max. Negotiated Rate |
$4,200.00 |
| Rate for Payer: BCBS Complete |
$4,200.00
|
| Rate for Payer: Mclaren Medicaid |
$4,000.00
|
| Rate for Payer: Meridian Medicaid |
$4,200.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,000.00
|
| Rate for Payer: UHC Medicaid |
$4,000.00
|
| Rate for Payer: UHCCP Medicaid |
$4,000.00
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$5,643.57
|
|
|
Service Code
|
APR-DRG 5313
|
| Min. Negotiated Rate |
$5,374.82 |
| Max. Negotiated Rate |
$5,643.57 |
| Rate for Payer: BCBS Complete |
$5,643.57
|
| Rate for Payer: Mclaren Medicaid |
$5,374.82
|
| Rate for Payer: Meridian Medicaid |
$5,643.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,374.82
|
| Rate for Payer: UHC Medicaid |
$5,374.82
|
| Rate for Payer: UHCCP Medicaid |
$5,374.82
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$6,097.05
|
|
|
Service Code
|
APR-DRG 5302
|
| Min. Negotiated Rate |
$5,806.71 |
| Max. Negotiated Rate |
$6,097.05 |
| Rate for Payer: BCBS Complete |
$6,097.05
|
| Rate for Payer: Mclaren Medicaid |
$5,806.71
|
| Rate for Payer: Meridian Medicaid |
$6,097.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,806.71
|
| Rate for Payer: UHC Medicaid |
$5,806.71
|
| Rate for Payer: UHCCP Medicaid |
$5,806.71
|
|
