|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$18.58 |
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$131.88
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Medicare |
$77.58
|
| Rate for Payer: Aetna Medicare |
$6.06
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: Aetna Medicare |
$6.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.77
|
| Rate for Payer: BCBS Complete |
$62.06
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: BCBS Complete |
$4.85
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.11
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$8.49
|
| Rate for Payer: Cofinity Commercial |
$9.44
|
| Rate for Payer: Cofinity Commercial |
$108.60
|
| Rate for Payer: Cofinity Commercial |
$133.43
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$18.58
|
| Rate for Payer: Healthscope Commercial |
$139.64
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$131.88
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.77
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$97.74
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$155.15
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.74 |
| Max. Negotiated Rate |
$139.64 |
| Rate for Payer: Aetna Commercial |
$131.88
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$9.44
|
| Rate for Payer: Cofinity Commercial |
$133.43
|
| Rate for Payer: Cofinity Commercial |
$108.60
|
| Rate for Payer: Cofinity Commercial |
$8.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$18.58
|
| Rate for Payer: Healthscope Commercial |
$139.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$131.88
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$97.74
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| Rate for Payer: Priority Health SBD |
$13.01
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 00054319446
|
| Hospital Charge Code |
2515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.99 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna Medicare |
$156.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health SBD |
$196.86
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$312.48
|
|
|
Service Code
|
NDC 00054319446
|
| Hospital Charge Code |
2515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.86 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health SBD |
$196.86
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.16 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna Medicare |
$181.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.88
|
| Rate for Payer: BCBS Complete |
$145.16
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$254.03
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$254.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$326.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health SBD |
$228.63
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$228.63 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.88
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$254.03
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$254.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$326.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health SBD |
$228.63
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.86 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health SBD |
$196.86
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.99 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna Medicare |
$156.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health SBD |
$196.86
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE
|
Facility
|
OP
|
$118.78
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.51 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: Aetna Medicare |
$59.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.21
|
| Rate for Payer: BCBS Complete |
$47.51
|
| Rate for Payer: BCBS Trust/PPO |
$81.87
|
| Rate for Payer: BCN Commercial |
$81.87
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Commercial |
$102.15
|
| Rate for Payer: Cofinity Commercial |
$83.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.02
|
| Rate for Payer: Healthscope Commercial |
$106.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.21
|
| Rate for Payer: Priority Health SBD |
$74.83
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE
|
Facility
|
IP
|
$118.78
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.83 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.21
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Commercial |
$102.15
|
| Rate for Payer: Cofinity Commercial |
$83.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.02
|
| Rate for Payer: Healthscope Commercial |
$106.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.21
|
| Rate for Payer: Priority Health SBD |
$74.83
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.39 |
| Max. Negotiated Rate |
$149.13 |
| Rate for Payer: Aetna Commercial |
$140.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.70
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$115.99
|
| Rate for Payer: Cofinity Commercial |
$142.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$149.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: PHP Commercial |
$140.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health SBD |
$104.39
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.28 |
| Max. Negotiated Rate |
$149.13 |
| Rate for Payer: Aetna Commercial |
$140.84
|
| Rate for Payer: Aetna Medicare |
$82.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.70
|
| Rate for Payer: BCBS Complete |
$66.28
|
| Rate for Payer: BCBS Trust/PPO |
$133.19
|
| Rate for Payer: BCN Commercial |
$133.19
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$115.99
|
| Rate for Payer: Cofinity Commercial |
$142.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$149.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: PHP Commercial |
$140.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health SBD |
$104.39
|
|
|
DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION
|
Facility
|
OP
|
$16,646.50
|
|
|
Service Code
|
CPT 35011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,077.33 |
| Max. Negotiated Rate |
$16,646.50 |
| Rate for Payer: Aetna Medicare |
$5,508.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,620.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,620.50
|
| Rate for Payer: BCBS Complete |
$2,980.81
|
| Rate for Payer: BCBS MAPPO |
$5,296.40
|
| Rate for Payer: BCBS Trust/PPO |
$2,103.52
|
| Rate for Payer: BCN Commercial |
$2,103.52
|
| Rate for Payer: BCN Medicare Advantage |
$5,296.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,296.40
|
| Rate for Payer: Mclaren Medicaid |
$2,838.87
|
| Rate for Payer: Mclaren Medicare |
$5,296.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,561.22
|
| Rate for Payer: Meridian Medicaid |
$2,980.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,090.86
|
| Rate for Payer: Nomi Health Commercial |
$11,122.44
|
| Rate for Payer: PACE Medicare |
$5,031.58
|
| Rate for Payer: PACE SWMI |
$5,296.40
|
| Rate for Payer: PHP Medicare Advantage |
$5,296.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,838.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,646.50
|
| Rate for Payer: Priority Health Medicare |
$5,296.40
|
| Rate for Payer: Priority Health Narrow Network |
$13,317.20
|
| Rate for Payer: Railroad Medicare Medicare |
$5,296.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,077.33
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,296.40
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,296.40
|
| Rate for Payer: UHCCP Medicaid |
$2,981.87
|
| Rate for Payer: VA VA |
$5,296.40
|
|
|
DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)
|
Facility
|
OP
|
$16,646.50
|
|
|
Service Code
|
CPT 36838
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,216.45 |
| Max. Negotiated Rate |
$16,646.50 |
| Rate for Payer: Aetna Medicare |
$5,508.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,620.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,620.50
|
| Rate for Payer: BCBS Complete |
$2,980.81
|
| Rate for Payer: BCBS MAPPO |
$5,296.40
|
| Rate for Payer: BCBS Trust/PPO |
$2,103.52
|
| Rate for Payer: BCN Commercial |
$2,103.52
|
| Rate for Payer: BCN Medicare Advantage |
$5,296.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,296.40
|
| Rate for Payer: Mclaren Medicaid |
$2,838.87
|
| Rate for Payer: Mclaren Medicare |
$5,296.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,561.22
|
| Rate for Payer: Meridian Medicaid |
$2,980.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,090.86
|
| Rate for Payer: Nomi Health Commercial |
$11,122.44
|
| Rate for Payer: PACE Medicare |
$5,031.58
|
| Rate for Payer: PACE SWMI |
$5,296.40
|
| Rate for Payer: PHP Medicare Advantage |
$5,296.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,838.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,646.50
|
| Rate for Payer: Priority Health Medicare |
$5,296.40
|
| Rate for Payer: Priority Health Narrow Network |
$13,317.20
|
| Rate for Payer: Railroad Medicare Medicare |
$5,296.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,216.45
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,296.40
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,296.40
|
| Rate for Payer: UHCCP Medicaid |
$2,981.87
|
| Rate for Payer: VA VA |
$5,296.40
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$373.92
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.57 |
| Max. Negotiated Rate |
$336.53 |
| Rate for Payer: Aetna Commercial |
$317.83
|
| Rate for Payer: Aetna Medicare |
$186.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.05
|
| Rate for Payer: BCBS Complete |
$149.57
|
| Rate for Payer: Cash Price |
$299.14
|
| Rate for Payer: Cofinity Commercial |
$261.74
|
| Rate for Payer: Cofinity Commercial |
$321.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$299.14
|
| Rate for Payer: Healthscope Commercial |
$336.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.83
|
| Rate for Payer: PHP Commercial |
$317.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.05
|
| Rate for Payer: Priority Health SBD |
$235.57
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 68084031311
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$373.92
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$235.57 |
| Max. Negotiated Rate |
$336.53 |
| Rate for Payer: Aetna Commercial |
$317.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.05
|
| Rate for Payer: Cash Price |
$299.14
|
| Rate for Payer: Cofinity Commercial |
$261.74
|
| Rate for Payer: Cofinity Commercial |
$321.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$299.14
|
| Rate for Payer: Healthscope Commercial |
$336.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.83
|
| Rate for Payer: PHP Commercial |
$317.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.05
|
| Rate for Payer: Priority Health SBD |
$235.57
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 68084031311
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna Medicare |
$1.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: BCBS Complete |
$1.50
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$371.45
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.58 |
| Max. Negotiated Rate |
$334.30 |
| Rate for Payer: Aetna Commercial |
$315.73
|
| Rate for Payer: Aetna Medicare |
$185.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.44
|
| Rate for Payer: BCBS Complete |
$148.58
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cofinity Commercial |
$260.02
|
| Rate for Payer: Cofinity Commercial |
$319.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$260.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.16
|
| Rate for Payer: Healthscope Commercial |
$334.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.73
|
| Rate for Payer: PHP Commercial |
$315.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.44
|
| Rate for Payer: Priority Health SBD |
$234.01
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$371.45
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.01 |
| Max. Negotiated Rate |
$334.30 |
| Rate for Payer: Aetna Commercial |
$315.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.44
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cofinity Commercial |
$260.02
|
| Rate for Payer: Cofinity Commercial |
$319.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$260.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.16
|
| Rate for Payer: Healthscope Commercial |
$334.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.73
|
| Rate for Payer: PHP Commercial |
$315.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.44
|
| Rate for Payer: Priority Health SBD |
$234.01
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$2.94
|
|
|
Service Code
|
NDC 60687021111
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna Commercial |
$2.50
|
| Rate for Payer: Aetna Medicare |
$1.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.91
|
| Rate for Payer: BCBS Complete |
$1.18
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.35
|
| Rate for Payer: Healthscope Commercial |
$2.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.50
|
| Rate for Payer: PHP Commercial |
$2.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.91
|
| Rate for Payer: Priority Health SBD |
$1.85
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$87.99
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.43 |
| Max. Negotiated Rate |
$79.19 |
| Rate for Payer: Aetna Commercial |
$74.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.19
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Cofinity Commercial |
$61.59
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.39
|
| Rate for Payer: Healthscope Commercial |
$79.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.79
|
| Rate for Payer: PHP Commercial |
$74.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.19
|
| Rate for Payer: Priority Health SBD |
$55.43
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$87.99
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.20 |
| Max. Negotiated Rate |
$79.19 |
| Rate for Payer: Aetna Commercial |
$74.79
|
| Rate for Payer: Aetna Medicare |
$44.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.19
|
| Rate for Payer: BCBS Complete |
$35.20
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Cofinity Commercial |
$61.59
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.39
|
| Rate for Payer: Healthscope Commercial |
$79.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.79
|
| Rate for Payer: PHP Commercial |
$74.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.19
|
| Rate for Payer: Priority Health SBD |
$55.43
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.35 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Cofinity Commercial |
$97.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health SBD |
$87.35
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$138.65
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.46 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna Medicare |
$69.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: BCBS Complete |
$55.46
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Cofinity Commercial |
$97.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health SBD |
$87.35
|
|
