|
EPCORITAMAB-BYSP 0.8 MG/ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$5,927.03
|
|
|
Service Code
|
HCPCS J9321
|
| Hospital Charge Code |
301960
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.93 |
| Max. Negotiated Rate |
$5,334.33 |
| Rate for Payer: Aetna Commercial |
$5,037.98
|
| Rate for Payer: Aetna Medicare |
$58.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,852.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$69.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$69.80
|
| Rate for Payer: BCBS Complete |
$31.43
|
| Rate for Payer: BCBS MAPPO |
$55.84
|
| Rate for Payer: BCN Medicare Advantage |
$55.84
|
| Rate for Payer: Cash Price |
$4,741.62
|
| Rate for Payer: Cash Price |
$4,741.62
|
| Rate for Payer: Cofinity Commercial |
$4,148.92
|
| Rate for Payer: Cofinity Commercial |
$5,097.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,148.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,741.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$5,334.33
|
| Rate for Payer: Mclaren Medicaid |
$29.93
|
| Rate for Payer: Mclaren Medicare |
$55.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$58.63
|
| Rate for Payer: Meridian Medicaid |
$31.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$64.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,037.98
|
| Rate for Payer: PACE Medicare |
$53.05
|
| Rate for Payer: PACE SWMI |
$55.84
|
| Rate for Payer: PHP Commercial |
$5,037.98
|
| Rate for Payer: PHP Medicare Advantage |
$55.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,852.57
|
| Rate for Payer: Priority Health Medicare |
$55.84
|
| Rate for Payer: Priority Health SBD |
$3,734.03
|
| Rate for Payer: Railroad Medicare Medicare |
$55.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$55.84
|
| Rate for Payer: UHC Medicare Advantage |
$55.84
|
| Rate for Payer: UHCCP Medicaid |
$31.44
|
| Rate for Payer: VA VA |
$55.84
|
|
|
EPCORITAMAB-BYSP 48 MG/0.8 ML SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$71,123.22
|
|
|
Service Code
|
HCPCS J9321
|
| Hospital Charge Code |
204020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.93 |
| Max. Negotiated Rate |
$64,010.90 |
| Rate for Payer: Aetna Commercial |
$60,454.74
|
| Rate for Payer: Aetna Medicare |
$58.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46,230.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$69.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$69.80
|
| Rate for Payer: BCBS Complete |
$31.43
|
| Rate for Payer: BCBS MAPPO |
$55.84
|
| Rate for Payer: BCN Medicare Advantage |
$55.84
|
| Rate for Payer: Cash Price |
$56,898.58
|
| Rate for Payer: Cash Price |
$56,898.58
|
| Rate for Payer: Cofinity Commercial |
$49,786.25
|
| Rate for Payer: Cofinity Commercial |
$61,165.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$49,786.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56,898.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$64,010.90
|
| Rate for Payer: Mclaren Medicaid |
$29.93
|
| Rate for Payer: Mclaren Medicare |
$55.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$58.63
|
| Rate for Payer: Meridian Medicaid |
$31.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$64.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60,454.74
|
| Rate for Payer: PACE Medicare |
$53.05
|
| Rate for Payer: PACE SWMI |
$55.84
|
| Rate for Payer: PHP Commercial |
$60,454.74
|
| Rate for Payer: PHP Medicare Advantage |
$55.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46,230.09
|
| Rate for Payer: Priority Health Medicare |
$55.84
|
| Rate for Payer: Priority Health SBD |
$44,807.63
|
| Rate for Payer: Railroad Medicare Medicare |
$55.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$55.84
|
| Rate for Payer: UHC Medicare Advantage |
$55.84
|
| Rate for Payer: UHCCP Medicaid |
$31.44
|
| Rate for Payer: VA VA |
$55.84
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$48.64
|
|
|
Service Code
|
NDC 51754425001
|
| Hospital Charge Code |
199572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.64 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Aetna Commercial |
$41.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.62
|
| Rate for Payer: Cash Price |
$38.91
|
| Rate for Payer: Cofinity Commercial |
$34.05
|
| Rate for Payer: Cofinity Commercial |
$41.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.91
|
| Rate for Payer: Healthscope Commercial |
$43.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.34
|
| Rate for Payer: PHP Commercial |
$41.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.62
|
| Rate for Payer: Priority Health SBD |
$30.64
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$48.64
|
|
|
Service Code
|
NDC 51754425003
|
| Hospital Charge Code |
199572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.46 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Aetna Commercial |
$41.34
|
| Rate for Payer: Aetna Medicare |
$24.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.62
|
| Rate for Payer: BCBS Complete |
$19.46
|
| Rate for Payer: Cash Price |
$38.91
|
| Rate for Payer: Cofinity Commercial |
$34.05
|
| Rate for Payer: Cofinity Commercial |
$41.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.91
|
| Rate for Payer: Healthscope Commercial |
$43.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.34
|
| Rate for Payer: PHP Commercial |
$41.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.62
|
| Rate for Payer: Priority Health SBD |
$30.64
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$48.64
|
|
|
Service Code
|
NDC 51754425001
|
| Hospital Charge Code |
199572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.46 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Aetna Commercial |
$41.34
|
| Rate for Payer: Aetna Medicare |
$24.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.62
|
| Rate for Payer: BCBS Complete |
$19.46
|
| Rate for Payer: Cash Price |
$38.91
|
| Rate for Payer: Cofinity Commercial |
$34.05
|
| Rate for Payer: Cofinity Commercial |
$41.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.91
|
| Rate for Payer: Healthscope Commercial |
$43.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.34
|
| Rate for Payer: PHP Commercial |
$41.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.62
|
| Rate for Payer: Priority Health SBD |
$30.64
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$48.64
|
|
|
Service Code
|
NDC 51754425003
|
| Hospital Charge Code |
199572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.64 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Aetna Commercial |
$41.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.62
|
| Rate for Payer: Cash Price |
$38.91
|
| Rate for Payer: Cofinity Commercial |
$34.05
|
| Rate for Payer: Cofinity Commercial |
$41.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.91
|
| Rate for Payer: Healthscope Commercial |
$43.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.34
|
| Rate for Payer: PHP Commercial |
$41.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.62
|
| Rate for Payer: Priority Health SBD |
$30.64
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$34.71
|
|
|
Service Code
|
NDC 70121163705
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.87 |
| Max. Negotiated Rate |
$31.24 |
| Rate for Payer: Aetna Commercial |
$29.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.56
|
| Rate for Payer: Cash Price |
$27.77
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Commercial |
$29.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.77
|
| Rate for Payer: Healthscope Commercial |
$31.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.50
|
| Rate for Payer: PHP Commercial |
$29.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.56
|
| Rate for Payer: Priority Health SBD |
$21.87
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$18.07
|
|
|
Service Code
|
NDC 55150037301
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.38 |
| Max. Negotiated Rate |
$16.26 |
| Rate for Payer: Aetna Commercial |
$15.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.75
|
| Rate for Payer: Cash Price |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$12.65
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.46
|
| Rate for Payer: Healthscope Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.36
|
| Rate for Payer: PHP Commercial |
$15.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.75
|
| Rate for Payer: Priority Health SBD |
$11.38
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 00641623801
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$15.65
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$34.71
|
|
|
Service Code
|
NDC 70121163705
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$31.24 |
| Rate for Payer: Aetna Commercial |
$29.50
|
| Rate for Payer: Aetna Medicare |
$17.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.56
|
| Rate for Payer: BCBS Complete |
$13.88
|
| Rate for Payer: Cash Price |
$27.77
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Commercial |
$29.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.77
|
| Rate for Payer: Healthscope Commercial |
$31.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.50
|
| Rate for Payer: PHP Commercial |
$29.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.56
|
| Rate for Payer: Priority Health SBD |
$21.87
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$18.07
|
|
|
Service Code
|
NDC 55150037301
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$16.26 |
| Rate for Payer: Aetna Commercial |
$15.36
|
| Rate for Payer: Aetna Medicare |
$9.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.75
|
| Rate for Payer: BCBS Complete |
$7.23
|
| Rate for Payer: Cash Price |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$12.65
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.46
|
| Rate for Payer: Healthscope Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.36
|
| Rate for Payer: PHP Commercial |
$15.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.75
|
| Rate for Payer: Priority Health SBD |
$11.38
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$28.97
|
|
|
Service Code
|
NDC 65219025701
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.59 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna Medicare |
$14.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: BCBS Complete |
$11.59
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.83
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$18.07
|
|
|
Service Code
|
NDC 55150037325
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.38 |
| Max. Negotiated Rate |
$16.26 |
| Rate for Payer: Aetna Commercial |
$15.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.75
|
| Rate for Payer: Cash Price |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$12.65
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.46
|
| Rate for Payer: Healthscope Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.36
|
| Rate for Payer: PHP Commercial |
$15.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.75
|
| Rate for Payer: Priority Health SBD |
$11.38
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 00641623825
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$15.65
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$31.11
|
|
|
Service Code
|
NDC 70121163701
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.44 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$26.44
|
| Rate for Payer: Aetna Medicare |
$15.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.22
|
| Rate for Payer: BCBS Complete |
$12.44
|
| Rate for Payer: Cash Price |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$21.78
|
| Rate for Payer: Cofinity Commercial |
$26.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.89
|
| Rate for Payer: Healthscope Commercial |
$28.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.44
|
| Rate for Payer: PHP Commercial |
$26.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.22
|
| Rate for Payer: Priority Health SBD |
$19.60
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$28.97
|
|
|
Service Code
|
NDC 65219025701
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.83
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 00641623801
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.94 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$15.65
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$31.11
|
|
|
Service Code
|
NDC 70121163701
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$26.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.22
|
| Rate for Payer: Cash Price |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$21.78
|
| Rate for Payer: Cofinity Commercial |
$26.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.89
|
| Rate for Payer: Healthscope Commercial |
$28.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.44
|
| Rate for Payer: PHP Commercial |
$26.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.22
|
| Rate for Payer: Priority Health SBD |
$19.60
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$18.07
|
|
|
Service Code
|
NDC 55150037325
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$16.26 |
| Rate for Payer: Aetna Commercial |
$15.36
|
| Rate for Payer: Aetna Medicare |
$9.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.75
|
| Rate for Payer: BCBS Complete |
$7.23
|
| Rate for Payer: Cash Price |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$12.65
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.46
|
| Rate for Payer: Healthscope Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.36
|
| Rate for Payer: PHP Commercial |
$15.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.75
|
| Rate for Payer: Priority Health SBD |
$11.38
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 00641623825
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.94 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$15.65
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
IP
|
$28.97
|
|
|
Service Code
|
NDC 65219025700
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.83
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INJECTION WRAPPER
|
Facility
|
OP
|
$28.97
|
|
|
Service Code
|
NDC 65219025700
|
| Hospital Charge Code |
300142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.59 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna Medicare |
$14.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: BCBS Complete |
$11.59
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.83
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
179024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Commercial |
$15.78
|
| Rate for Payer: Aetna Commercial |
$15.36
|
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$14.46
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Cofinity Commercial |
$12.65
|
| Rate for Payer: Cofinity Commercial |
$12.99
|
| Rate for Payer: Cofinity Commercial |
$15.96
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.85
|
| Rate for Payer: Healthscope Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Commercial |
$16.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.36
|
| Rate for Payer: PHP Commercial |
$15.78
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: PHP Commercial |
$15.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.06
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$11.38
|
| Rate for Payer: Priority Health SBD |
$11.69
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
179024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.94 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Commercial |
$15.78
|
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: Aetna Commercial |
$15.36
|
| Rate for Payer: Aetna Medicare |
$14.48
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna Medicare |
$9.28
|
| Rate for Payer: Aetna Medicare |
$9.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.83
|
| Rate for Payer: BCBS Complete |
$7.23
|
| Rate for Payer: BCBS Complete |
$11.59
|
| Rate for Payer: BCBS Complete |
$7.42
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: Cash Price |
$23.18
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$15.96
|
| Rate for Payer: Cofinity Commercial |
$24.91
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$12.65
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$12.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.85
|
| Rate for Payer: Healthscope Commercial |
$16.26
|
| Rate for Payer: Healthscope Commercial |
$26.07
|
| Rate for Payer: Healthscope Commercial |
$16.70
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.36
|
| Rate for Payer: PHP Commercial |
$15.78
|
| Rate for Payer: PHP Commercial |
$24.62
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$15.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.83
|
| Rate for Payer: Priority Health SBD |
$11.38
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$11.69
|
| Rate for Payer: Priority Health SBD |
$18.25
|
|
|
EPIDIDYMECTOMY; UNILATERAL
|
Facility
|
OP
|
$9,468.51
|
|
|
Service Code
|
CPT 54860
|
|
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
|
|
