|
EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RENAL, CELIAC, MESENTERY, AORTOILIAC ARTERY, BY ABDOMINAL INCISION
|
Facility
|
OP
|
$3,362.00
|
|
|
Service Code
|
CPT 34151
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,484.52 |
| Max. Negotiated Rate |
$3,362.00 |
| Rate for Payer: BCBS Trust/PPO |
$2,978.08
|
| Rate for Payer: BCN Commercial |
$2,978.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,484.52
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$900.56 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$900.56 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$571.78 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$714.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$571.78 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$714.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$571.78 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$714.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$900.56 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$900.56 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$571.78 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$714.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
IP
|
$50.99
|
|
|
Service Code
|
NDC 00264975706
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.12 |
| Max. Negotiated Rate |
$45.89 |
| Rate for Payer: Aetna Commercial |
$43.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.14
|
| Rate for Payer: Cash Price |
$40.79
|
| Rate for Payer: Cofinity Commercial |
$35.69
|
| Rate for Payer: Cofinity Commercial |
$43.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.79
|
| Rate for Payer: Healthscope Commercial |
$45.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.34
|
| Rate for Payer: PHP Commercial |
$43.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.14
|
| Rate for Payer: Priority Health SBD |
$32.12
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
OP
|
$50.99
|
|
|
Service Code
|
NDC 00264975706
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$45.89 |
| Rate for Payer: Aetna Commercial |
$43.34
|
| Rate for Payer: Aetna Medicare |
$25.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.14
|
| Rate for Payer: BCBS Complete |
$20.40
|
| Rate for Payer: Cash Price |
$40.79
|
| Rate for Payer: Cofinity Commercial |
$35.69
|
| Rate for Payer: Cofinity Commercial |
$43.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.79
|
| Rate for Payer: Healthscope Commercial |
$45.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.34
|
| Rate for Payer: PHP Commercial |
$43.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.14
|
| Rate for Payer: Priority Health SBD |
$32.12
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET
|
Facility
|
IP
|
$7,944.83
|
|
|
Service Code
|
NDC 61958200201
|
| Hospital Charge Code |
178497
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,005.24 |
| Max. Negotiated Rate |
$7,150.35 |
| Rate for Payer: Aetna Commercial |
$6,753.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,164.14
|
| Rate for Payer: Cash Price |
$6,355.86
|
| Rate for Payer: Cofinity Commercial |
$5,561.38
|
| Rate for Payer: Cofinity Commercial |
$6,832.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,561.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,355.86
|
| Rate for Payer: Healthscope Commercial |
$7,150.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,753.11
|
| Rate for Payer: PHP Commercial |
$6,753.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,164.14
|
| Rate for Payer: Priority Health SBD |
$5,005.24
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET
|
Facility
|
OP
|
$7,944.83
|
|
|
Service Code
|
NDC 61958200201
|
| Hospital Charge Code |
178497
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,177.93 |
| Max. Negotiated Rate |
$7,150.35 |
| Rate for Payer: Aetna Commercial |
$6,753.11
|
| Rate for Payer: Aetna Medicare |
$3,972.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,164.14
|
| Rate for Payer: BCBS Complete |
$3,177.93
|
| Rate for Payer: Cash Price |
$6,355.86
|
| Rate for Payer: Cofinity Commercial |
$5,561.38
|
| Rate for Payer: Cofinity Commercial |
$6,832.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,561.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,355.86
|
| Rate for Payer: Healthscope Commercial |
$7,150.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,753.11
|
| Rate for Payer: PHP Commercial |
$6,753.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,164.14
|
| Rate for Payer: Priority Health SBD |
$5,005.24
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
OP
|
$87.84
|
|
|
Service Code
|
NDC 42385095330
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.14 |
| Max. Negotiated Rate |
$79.06 |
| Rate for Payer: Aetna Commercial |
$74.66
|
| Rate for Payer: Aetna Medicare |
$43.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.10
|
| Rate for Payer: BCBS Complete |
$35.14
|
| Rate for Payer: Cash Price |
$70.27
|
| Rate for Payer: Cofinity Commercial |
$61.49
|
| Rate for Payer: Cofinity Commercial |
$75.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.27
|
| Rate for Payer: Healthscope Commercial |
$79.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.66
|
| Rate for Payer: PHP Commercial |
$74.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.10
|
| Rate for Payer: Priority Health SBD |
$55.34
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
IP
|
$6,646.02
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,186.99 |
| Max. Negotiated Rate |
$5,981.42 |
| Rate for Payer: Aetna Commercial |
$5,649.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,319.91
|
| Rate for Payer: Cash Price |
$5,316.82
|
| Rate for Payer: Cofinity Commercial |
$4,652.21
|
| Rate for Payer: Cofinity Commercial |
$5,715.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,652.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,316.82
|
| Rate for Payer: Healthscope Commercial |
$5,981.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,649.12
|
| Rate for Payer: PHP Commercial |
$5,649.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,319.91
|
| Rate for Payer: Priority Health SBD |
$4,186.99
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
IP
|
$87.84
|
|
|
Service Code
|
NDC 42385095330
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.34 |
| Max. Negotiated Rate |
$79.06 |
| Rate for Payer: Aetna Commercial |
$74.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.10
|
| Rate for Payer: Cash Price |
$70.27
|
| Rate for Payer: Cofinity Commercial |
$61.49
|
| Rate for Payer: Cofinity Commercial |
$75.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.27
|
| Rate for Payer: Healthscope Commercial |
$79.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.66
|
| Rate for Payer: PHP Commercial |
$74.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.10
|
| Rate for Payer: Priority Health SBD |
$55.34
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
OP
|
$6,646.02
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,658.41 |
| Max. Negotiated Rate |
$5,981.42 |
| Rate for Payer: Aetna Commercial |
$5,649.12
|
| Rate for Payer: Aetna Medicare |
$3,323.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,319.91
|
| Rate for Payer: BCBS Complete |
$2,658.41
|
| Rate for Payer: Cash Price |
$5,316.82
|
| Rate for Payer: Cofinity Commercial |
$4,652.21
|
| Rate for Payer: Cofinity Commercial |
$5,715.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,652.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,316.82
|
| Rate for Payer: Healthscope Commercial |
$5,981.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,649.12
|
| Rate for Payer: PHP Commercial |
$5,649.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,319.91
|
| Rate for Payer: Priority Health SBD |
$4,186.99
|
|
|
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$57.56
|
|
|
Service Code
|
NDC 00143978610
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$48.93
|
| Rate for Payer: Aetna Medicare |
$28.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.41
|
| Rate for Payer: BCBS Complete |
$23.02
|
| Rate for Payer: Cash Price |
$46.05
|
| Rate for Payer: Cofinity Commercial |
$40.29
|
| Rate for Payer: Cofinity Commercial |
$49.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.05
|
| Rate for Payer: Healthscope Commercial |
$51.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.93
|
| Rate for Payer: PHP Commercial |
$48.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.41
|
| Rate for Payer: Priority Health SBD |
$36.26
|
|
|
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$57.56
|
|
|
Service Code
|
NDC 00143978610
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.26 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$48.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.41
|
| Rate for Payer: Cash Price |
$46.05
|
| Rate for Payer: Cofinity Commercial |
$40.29
|
| Rate for Payer: Cofinity Commercial |
$49.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.05
|
| Rate for Payer: Healthscope Commercial |
$51.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.93
|
| Rate for Payer: PHP Commercial |
$48.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.41
|
| Rate for Payer: Priority Health SBD |
$36.26
|
|
|
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$57.56
|
|
|
Service Code
|
NDC 00143978601
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.26 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$48.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.41
|
| Rate for Payer: Cash Price |
$46.05
|
| Rate for Payer: Cofinity Commercial |
$40.29
|
| Rate for Payer: Cofinity Commercial |
$49.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.05
|
| Rate for Payer: Healthscope Commercial |
$51.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.93
|
| Rate for Payer: PHP Commercial |
$48.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.41
|
| Rate for Payer: Priority Health SBD |
$36.26
|
|
|
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$57.56
|
|
|
Service Code
|
NDC 00143978601
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$48.93
|
| Rate for Payer: Aetna Medicare |
$28.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.41
|
| Rate for Payer: BCBS Complete |
$23.02
|
| Rate for Payer: Cash Price |
$46.05
|
| Rate for Payer: Cofinity Commercial |
$40.29
|
| Rate for Payer: Cofinity Commercial |
$49.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.05
|
| Rate for Payer: Healthscope Commercial |
$51.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.93
|
| Rate for Payer: PHP Commercial |
$48.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.41
|
| Rate for Payer: Priority Health SBD |
$36.26
|
|
|
ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND CURETTAGE)
|
Facility
|
OP
|
$2,681.40
|
|
|
Service Code
|
CPT 57505
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$114.64 |
| Max. Negotiated Rate |
$2,681.40 |
| Rate for Payer: Aetna Medicare |
$887.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,066.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,066.41
|
| Rate for Payer: BCBS Complete |
$480.14
|
| Rate for Payer: BCBS MAPPO |
$853.13
|
| Rate for Payer: BCBS Trust/PPO |
$452.82
|
| Rate for Payer: BCCCP Commercial |
$145.60
|
| Rate for Payer: BCN Commercial |
$452.82
|
| Rate for Payer: BCN Medicare Advantage |
$853.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$853.13
|
| Rate for Payer: Mclaren Medicaid |
$457.28
|
| Rate for Payer: Mclaren Medicare |
$853.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$895.79
|
| Rate for Payer: Meridian Medicaid |
$480.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$981.10
|
| Rate for Payer: Nomi Health Commercial |
$1,791.57
|
| Rate for Payer: PACE Medicare |
$810.47
|
| Rate for Payer: PACE SWMI |
$853.13
|
| Rate for Payer: PHP Medicare Advantage |
$853.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$457.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,681.40
|
| Rate for Payer: Priority Health Medicare |
$853.13
|
| Rate for Payer: Priority Health Narrow Network |
$2,145.12
|
| Rate for Payer: Railroad Medicare Medicare |
$853.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$114.64
|
| Rate for Payer: UHC Core |
$1,463.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$853.13
|
| Rate for Payer: UHC Exchange |
$1,566.00
|
| Rate for Payer: UHC Medicare Advantage |
$853.13
|
| Rate for Payer: UHCCP Medicaid |
$480.31
|
| Rate for Payer: VA VA |
$853.13
|
|
|
ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE
|
Facility
|
OP
|
$15,201.47
|
|
|
Service Code
|
CPT 58353
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$245.90 |
| Max. Negotiated Rate |
$15,201.47 |
| Rate for Payer: Aetna Medicare |
$5,030.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,045.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,045.79
|
| Rate for Payer: BCBS Complete |
$2,722.06
|
| Rate for Payer: BCBS MAPPO |
$4,836.63
|
| Rate for Payer: BCBS Trust/PPO |
$2,069.95
|
| Rate for Payer: BCN Commercial |
$2,069.95
|
| Rate for Payer: BCN Medicare Advantage |
$4,836.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,836.63
|
| Rate for Payer: Mclaren Medicaid |
$2,592.43
|
| Rate for Payer: Mclaren Medicare |
$4,836.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,078.46
|
| Rate for Payer: Meridian Medicaid |
$2,722.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,562.12
|
| Rate for Payer: Nomi Health Commercial |
$10,156.92
|
| Rate for Payer: PACE Medicare |
$4,594.80
|
| Rate for Payer: PACE SWMI |
$4,836.63
|
| Rate for Payer: PHP Medicare Advantage |
$4,836.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,592.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,201.47
|
| Rate for Payer: Priority Health Medicare |
$4,836.63
|
| Rate for Payer: Priority Health Narrow Network |
$12,161.18
|
| Rate for Payer: Railroad Medicare Medicare |
$4,836.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$245.90
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,836.63
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$4,836.63
|
| Rate for Payer: UHCCP Medicaid |
$2,723.02
|
| Rate for Payer: VA VA |
$4,836.63
|
|
|
ENDOMETRIAL SAMPLING (BIOPSY) PERFORMED IN CONJUNCTION WITH COLPOSCOPY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
CPT 58110
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$43.08 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: BCBS Trust/PPO |
$98.61
|
| Rate for Payer: BCN Commercial |
$98.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$43.08
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$940.00
|
|
|
ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
CPT 58100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.78 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: Aetna Medicare |
$204.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$246.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$246.38
|
| Rate for Payer: BCBS Complete |
$110.93
|
| Rate for Payer: BCBS MAPPO |
$197.10
|
| Rate for Payer: BCBS Trust/PPO |
$75.89
|
| Rate for Payer: BCCCP Commercial |
$97.15
|
| Rate for Payer: BCN Commercial |
$75.89
|
| Rate for Payer: BCN Medicare Advantage |
$197.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$197.10
|
| Rate for Payer: Mclaren Medicaid |
$105.65
|
| Rate for Payer: Mclaren Medicare |
$197.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$206.96
|
| Rate for Payer: Meridian Medicaid |
$110.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$226.66
|
| Rate for Payer: Nomi Health Commercial |
$413.91
|
| Rate for Payer: PACE Medicare |
$187.24
|
| Rate for Payer: PACE SWMI |
$197.10
|
| Rate for Payer: PHP Medicare Advantage |
$197.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$105.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$619.50
|
| Rate for Payer: Priority Health Medicare |
$197.10
|
| Rate for Payer: Priority Health Narrow Network |
$495.60
|
| Rate for Payer: Railroad Medicare Medicare |
$197.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.78
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$197.10
|
| Rate for Payer: UHC Exchange |
$940.00
|
| Rate for Payer: UHC Medicare Advantage |
$197.10
|
| Rate for Payer: UHCCP Medicaid |
$110.97
|
| Rate for Payer: VA VA |
$197.10
|
|
