|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$631.68
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$397.96 |
| Max. Negotiated Rate |
$568.51 |
| Rate for Payer: Aetna Commercial |
$536.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$410.59
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cofinity Advantage |
$442.18
|
| Rate for Payer: Cofinity Commercial |
$543.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.34
|
| Rate for Payer: Healthscope Commercial |
$568.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$473.76
|
| Rate for Payer: PHP Commercial |
$536.93
|
| Rate for Payer: Priority Health SBD |
$397.96
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$631.68
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$568.51 |
| Rate for Payer: Aetna Commercial |
$536.93
|
| Rate for Payer: Aetna Medicare |
$315.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$410.59
|
| Rate for Payer: BCBS Complete |
$252.67
|
| Rate for Payer: BCBS Trust/PPO |
$21.30
|
| Rate for Payer: BCN Commercial |
$21.30
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cofinity Advantage |
$442.18
|
| Rate for Payer: Cofinity Commercial |
$543.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.34
|
| Rate for Payer: Healthscope Commercial |
$568.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$505.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$473.76
|
| Rate for Payer: PHP Commercial |
$536.93
|
| Rate for Payer: Priority Health SBD |
$397.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.34
|
| Rate for Payer: UHC Core |
$24.34
|
| Rate for Payer: UHC Exchange |
$24.34
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 68084072911
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.58 |
| Max. Negotiated Rate |
$13.68 |
| Rate for Payer: Aetna Commercial |
$12.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.88
|
| Rate for Payer: Cash Price |
$12.16
|
| Rate for Payer: Cofinity Advantage |
$10.64
|
| Rate for Payer: Cofinity Commercial |
$13.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.16
|
| Rate for Payer: Healthscope Commercial |
$13.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.40
|
| Rate for Payer: PHP Commercial |
$12.92
|
| Rate for Payer: Priority Health SBD |
$9.58
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$238.83
|
|
|
Service Code
|
NDC 70436000406
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.86 |
| Max. Negotiated Rate |
$214.95 |
| Rate for Payer: Aetna Commercial |
$203.01
|
| Rate for Payer: Aetna Medicare |
$119.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.24
|
| Rate for Payer: BCBS Complete |
$95.53
|
| Rate for Payer: Cash Price |
$191.06
|
| Rate for Payer: Cofinity Advantage |
$167.18
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.06
|
| Rate for Payer: Healthscope Commercial |
$214.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$191.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$179.12
|
| Rate for Payer: PHP Commercial |
$203.01
|
| Rate for Payer: Priority Health SBD |
$150.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$155.24
|
| Rate for Payer: UHC Core |
$124.43
|
| Rate for Payer: UHC Exchange |
$93.86
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$455.99
|
|
|
Service Code
|
NDC 68084072921
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.27 |
| Max. Negotiated Rate |
$410.39 |
| Rate for Payer: Aetna Commercial |
$387.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.39
|
| Rate for Payer: Cash Price |
$364.79
|
| Rate for Payer: Cofinity Advantage |
$319.19
|
| Rate for Payer: Cofinity Commercial |
$392.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.79
|
| Rate for Payer: Healthscope Commercial |
$410.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$341.99
|
| Rate for Payer: PHP Commercial |
$387.59
|
| Rate for Payer: Priority Health SBD |
$287.27
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$9.21
|
|
|
Service Code
|
NDC 51079085201
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$8.29 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Aetna Medicare |
$4.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.99
|
| Rate for Payer: BCBS Complete |
$3.68
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cofinity Advantage |
$6.45
|
| Rate for Payer: Cofinity Commercial |
$7.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.37
|
| Rate for Payer: Healthscope Commercial |
$8.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.91
|
| Rate for Payer: PHP Commercial |
$7.83
|
| Rate for Payer: Priority Health SBD |
$5.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.99
|
| Rate for Payer: UHC Core |
$4.80
|
| Rate for Payer: UHC Exchange |
$3.62
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$9.21
|
|
|
Service Code
|
NDC 51079085201
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$8.29 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.99
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cofinity Advantage |
$6.45
|
| Rate for Payer: Cofinity Commercial |
$7.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.37
|
| Rate for Payer: Healthscope Commercial |
$8.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.91
|
| Rate for Payer: PHP Commercial |
$7.83
|
| Rate for Payer: Priority Health SBD |
$5.80
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$238.83
|
|
|
Service Code
|
NDC 70436000406
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.46 |
| Max. Negotiated Rate |
$214.95 |
| Rate for Payer: Aetna Commercial |
$203.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.24
|
| Rate for Payer: Cash Price |
$191.06
|
| Rate for Payer: Cofinity Advantage |
$167.18
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.06
|
| Rate for Payer: Healthscope Commercial |
$214.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$179.12
|
| Rate for Payer: PHP Commercial |
$203.01
|
| Rate for Payer: Priority Health SBD |
$150.46
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$455.99
|
|
|
Service Code
|
NDC 68084072921
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.20 |
| Max. Negotiated Rate |
$410.39 |
| Rate for Payer: Aetna Commercial |
$387.59
|
| Rate for Payer: Aetna Medicare |
$228.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$296.39
|
| Rate for Payer: BCBS Complete |
$182.40
|
| Rate for Payer: Cash Price |
$364.79
|
| Rate for Payer: Cofinity Advantage |
$319.19
|
| Rate for Payer: Cofinity Commercial |
$392.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$364.79
|
| Rate for Payer: Healthscope Commercial |
$410.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$364.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$387.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$341.99
|
| Rate for Payer: PHP Commercial |
$387.59
|
| Rate for Payer: Priority Health SBD |
$287.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$296.39
|
| Rate for Payer: UHC Core |
$237.57
|
| Rate for Payer: UHC Exchange |
$179.20
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$276.06
|
|
|
Service Code
|
NDC 51079085203
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.49 |
| Max. Negotiated Rate |
$248.45 |
| Rate for Payer: Aetna Commercial |
$234.65
|
| Rate for Payer: Aetna Medicare |
$138.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.44
|
| Rate for Payer: BCBS Complete |
$110.42
|
| Rate for Payer: Cash Price |
$220.85
|
| Rate for Payer: Cofinity Advantage |
$193.24
|
| Rate for Payer: Cofinity Commercial |
$237.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.85
|
| Rate for Payer: Healthscope Commercial |
$248.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$220.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.04
|
| Rate for Payer: PHP Commercial |
$234.65
|
| Rate for Payer: Priority Health SBD |
$173.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$179.44
|
| Rate for Payer: UHC Core |
$143.83
|
| Rate for Payer: UHC Exchange |
$108.49
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$15.20
|
|
|
Service Code
|
NDC 68084072911
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.97 |
| Max. Negotiated Rate |
$13.68 |
| Rate for Payer: Aetna Commercial |
$12.92
|
| Rate for Payer: Aetna Medicare |
$7.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.88
|
| Rate for Payer: BCBS Complete |
$6.08
|
| Rate for Payer: Cash Price |
$12.16
|
| Rate for Payer: Cofinity Advantage |
$10.64
|
| Rate for Payer: Cofinity Commercial |
$13.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.16
|
| Rate for Payer: Healthscope Commercial |
$13.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.40
|
| Rate for Payer: PHP Commercial |
$12.92
|
| Rate for Payer: Priority Health SBD |
$9.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.88
|
| Rate for Payer: UHC Core |
$7.92
|
| Rate for Payer: UHC Exchange |
$5.97
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$276.06
|
|
|
Service Code
|
NDC 51079085203
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.92 |
| Max. Negotiated Rate |
$248.45 |
| Rate for Payer: Aetna Commercial |
$234.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.44
|
| Rate for Payer: Cash Price |
$220.85
|
| Rate for Payer: Cofinity Advantage |
$193.24
|
| Rate for Payer: Cofinity Commercial |
$237.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.85
|
| Rate for Payer: Healthscope Commercial |
$248.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.04
|
| Rate for Payer: PHP Commercial |
$234.65
|
| Rate for Payer: Priority Health SBD |
$173.92
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$154.08
|
|
|
Service Code
|
NDC 47335083583
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.07 |
| Max. Negotiated Rate |
$138.67 |
| Rate for Payer: Aetna Commercial |
$130.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.15
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cofinity Advantage |
$107.86
|
| Rate for Payer: Cofinity Commercial |
$132.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.26
|
| Rate for Payer: Healthscope Commercial |
$138.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$115.56
|
| Rate for Payer: PHP Commercial |
$130.97
|
| Rate for Payer: Priority Health SBD |
$97.07
|
|
|
GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$154.08
|
|
|
Service Code
|
NDC 47335083583
|
| Hospital Charge Code |
41138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.55 |
| Max. Negotiated Rate |
$138.67 |
| Rate for Payer: Aetna Commercial |
$130.97
|
| Rate for Payer: Aetna Medicare |
$77.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.15
|
| Rate for Payer: BCBS Complete |
$61.63
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cofinity Advantage |
$107.86
|
| Rate for Payer: Cofinity Commercial |
$132.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.26
|
| Rate for Payer: Healthscope Commercial |
$138.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$123.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$115.56
|
| Rate for Payer: PHP Commercial |
$130.97
|
| Rate for Payer: Priority Health SBD |
$97.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$100.15
|
| Rate for Payer: UHC Core |
$80.28
|
| Rate for Payer: UHC Exchange |
$60.55
|
|
|
GAMUNEX-C 10 GRAM/100 ML (10 %) INJECTION SOLUTION
|
Facility
|
OP
|
$4,544.30
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$4,089.87 |
| Rate for Payer: Aetna Commercial |
$3,862.66
|
| Rate for Payer: Aetna Medicare |
$51.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,953.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.16
|
| Rate for Payer: BCBS Complete |
$27.31
|
| Rate for Payer: BCBS MAPPO |
$49.73
|
| Rate for Payer: BCBS Trust/PPO |
$123.12
|
| Rate for Payer: BCN Commercial |
$123.12
|
| Rate for Payer: BCN Medicare Advantage |
$49.73
|
| Rate for Payer: Cash Price |
$3,635.44
|
| Rate for Payer: Cash Price |
$3,635.44
|
| Rate for Payer: Cofinity Advantage |
$3,181.01
|
| Rate for Payer: Cofinity Commercial |
$3,908.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,635.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49.73
|
| Rate for Payer: Healthscope Commercial |
$4,089.87
|
| Rate for Payer: Mclaren Medicaid |
$26.01
|
| Rate for Payer: Mclaren Medicare |
$49.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.22
|
| Rate for Payer: Meridian Medicaid |
$52.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.19
|
| Rate for Payer: Molina Medicare/Medicaid |
$54.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,862.66
|
| Rate for Payer: Nomi Health Commercial |
$149.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,408.22
|
| Rate for Payer: PACE Medicare |
$47.24
|
| Rate for Payer: PACE SWMI |
$49.73
|
| Rate for Payer: PHP Commercial |
$3,862.66
|
| Rate for Payer: PHP Medicare Advantage |
$49.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$154.42
|
| Rate for Payer: Priority Health Medicare |
$49.73
|
| Rate for Payer: Priority Health SBD |
$2,862.91
|
| Rate for Payer: Priority Health Tiered Network |
$123.54
|
| Rate for Payer: Railroad Medicare Medicare |
$49.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.98
|
| Rate for Payer: UHC Core |
$80.98
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$49.73
|
| Rate for Payer: UHC Exchange |
$80.98
|
| Rate for Payer: UHC Medicaid |
$26.01
|
| Rate for Payer: UHCCP Medicaid |
$26.01
|
| Rate for Payer: VA VA |
$49.73
|
|
|
GAMUNEX-C 10 GRAM/100 ML (10 %) INJECTION SOLUTION
|
Facility
|
IP
|
$4,544.30
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
107780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,862.91 |
| Max. Negotiated Rate |
$4,089.87 |
| Rate for Payer: Aetna Commercial |
$3,862.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,953.80
|
| Rate for Payer: Cash Price |
$3,635.44
|
| Rate for Payer: Cofinity Advantage |
$3,181.01
|
| Rate for Payer: Cofinity Commercial |
$3,908.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,635.44
|
| Rate for Payer: Healthscope Commercial |
$4,089.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,862.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,408.22
|
| Rate for Payer: PHP Commercial |
$3,862.66
|
| Rate for Payer: Priority Health SBD |
$2,862.91
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$199.77
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.86 |
| Max. Negotiated Rate |
$179.79 |
| Rate for Payer: Aetna Commercial |
$169.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.85
|
| Rate for Payer: Cash Price |
$159.82
|
| Rate for Payer: Cofinity Advantage |
$139.84
|
| Rate for Payer: Cofinity Commercial |
$171.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.82
|
| Rate for Payer: Healthscope Commercial |
$179.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$149.83
|
| Rate for Payer: PHP Commercial |
$169.80
|
| Rate for Payer: Priority Health SBD |
$125.86
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$199.77
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.31 |
| Max. Negotiated Rate |
$179.79 |
| Rate for Payer: Aetna Commercial |
$169.80
|
| Rate for Payer: Aetna Medicare |
$99.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.85
|
| Rate for Payer: BCBS Complete |
$79.91
|
| Rate for Payer: BCBS Trust/PPO |
$84.09
|
| Rate for Payer: BCN Commercial |
$84.09
|
| Rate for Payer: Cash Price |
$159.82
|
| Rate for Payer: Cash Price |
$159.82
|
| Rate for Payer: Cofinity Advantage |
$139.84
|
| Rate for Payer: Cofinity Commercial |
$171.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.82
|
| Rate for Payer: Healthscope Commercial |
$179.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$159.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$149.83
|
| Rate for Payer: PHP Commercial |
$169.80
|
| Rate for Payer: Priority Health SBD |
$125.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.31
|
| Rate for Payer: UHC Core |
$55.31
|
| Rate for Payer: UHC Exchange |
$55.31
|
|
|
GANCICLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$148.68
|
|
|
Service Code
|
NDC 25021018510
|
| Hospital Charge Code |
186410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.43 |
| Max. Negotiated Rate |
$133.81 |
| Rate for Payer: Aetna Commercial |
$126.38
|
| Rate for Payer: Aetna Medicare |
$74.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.64
|
| Rate for Payer: BCBS Complete |
$59.47
|
| Rate for Payer: Cash Price |
$118.94
|
| Rate for Payer: Cofinity Advantage |
$104.08
|
| Rate for Payer: Cofinity Commercial |
$127.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.94
|
| Rate for Payer: Healthscope Commercial |
$133.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$118.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.51
|
| Rate for Payer: PHP Commercial |
$126.38
|
| Rate for Payer: Priority Health SBD |
$93.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$96.64
|
| Rate for Payer: UHC Core |
$77.46
|
| Rate for Payer: UHC Exchange |
$58.43
|
|
|
GANCICLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$148.68
|
|
|
Service Code
|
NDC 25021018510
|
| Hospital Charge Code |
186410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.67 |
| Max. Negotiated Rate |
$133.81 |
| Rate for Payer: Aetna Commercial |
$126.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.64
|
| Rate for Payer: Cash Price |
$118.94
|
| Rate for Payer: Cofinity Advantage |
$104.08
|
| Rate for Payer: Cofinity Commercial |
$127.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.94
|
| Rate for Payer: Healthscope Commercial |
$133.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.51
|
| Rate for Payer: PHP Commercial |
$126.38
|
| Rate for Payer: Priority Health SBD |
$93.67
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH CC
|
Facility
|
IP
|
$18,607.02
|
|
|
Service Code
|
MSDRG 378
|
| Min. Negotiated Rate |
$7,750.17 |
| Max. Negotiated Rate |
$18,607.02 |
| Rate for Payer: Aetna Medicare |
$8,484.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,197.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,197.59
|
| Rate for Payer: BCBS MAPPO |
$8,158.07
|
| Rate for Payer: BCBS Trust/PPO |
$18,607.02
|
| Rate for Payer: BCN Commercial |
$18,607.02
|
| Rate for Payer: BCN Medicare Advantage |
$8,158.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,158.07
|
| Rate for Payer: Mclaren Medicare |
$8,158.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,565.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,381.78
|
| Rate for Payer: Molina Medicare/Medicaid |
$8,973.88
|
| Rate for Payer: Nomi Health Commercial |
$12,651.03
|
| Rate for Payer: PACE Medicare |
$7,750.17
|
| Rate for Payer: PACE SWMI |
$8,158.07
|
| Rate for Payer: PHP Medicare Advantage |
$8,158.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$15,810.98
|
| Rate for Payer: Priority Health Medicare |
$8,158.07
|
| Rate for Payer: Priority Health Tiered Network |
$12,648.78
|
| Rate for Payer: Railroad Medicare Medicare |
$8,158.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15,985.41
|
| Rate for Payer: UHC Core |
$13,373.81
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,158.07
|
| Rate for Payer: UHC Exchange |
$10,922.06
|
| Rate for Payer: VA VA |
$8,158.07
|
|
|
GASTROINTESTINAL HEMORRHAGE WITH MCC
|
Facility
|
IP
|
$29,796.40
|
|
|
Service Code
|
MSDRG 377
|
| Min. Negotiated Rate |
$13,970.89 |
| Max. Negotiated Rate |
$29,796.40 |
| Rate for Payer: Aetna Medicare |
$15,294.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,382.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,382.75
|
| Rate for Payer: BCBS MAPPO |
$14,706.20
|
| Rate for Payer: BCBS Trust/PPO |
$28,391.56
|
| Rate for Payer: BCN Commercial |
$28,391.56
|
| Rate for Payer: BCN Medicare Advantage |
$14,706.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,706.20
|
| Rate for Payer: Mclaren Medicare |
$14,706.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15,441.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,912.13
|
| Rate for Payer: Molina Medicare/Medicaid |
$16,176.82
|
| Rate for Payer: Nomi Health Commercial |
$23,581.20
|
| Rate for Payer: PACE Medicare |
$13,970.89
|
| Rate for Payer: PACE SWMI |
$14,706.20
|
| Rate for Payer: PHP Medicare Advantage |
$14,706.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$29,471.27
|
| Rate for Payer: Priority Health Medicare |
$14,706.20
|
| Rate for Payer: Priority Health Tiered Network |
$23,577.01
|
| Rate for Payer: Railroad Medicare Medicare |
$14,706.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29,796.40
|
| Rate for Payer: UHC Core |
$24,928.44
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$14,706.20
|
| Rate for Payer: UHC Exchange |
$20,358.44
|
| Rate for Payer: VA VA |
$14,706.20
|
|
|
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC
|
Facility
|
IP
|
$13,719.43
|
|
|
Service Code
|
MSDRG 379
|
| Min. Negotiated Rate |
$5,178.34 |
| Max. Negotiated Rate |
$13,719.43 |
| Rate for Payer: Aetna Medicare |
$5,668.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,813.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,813.60
|
| Rate for Payer: BCBS MAPPO |
$5,450.88
|
| Rate for Payer: BCBS Trust/PPO |
$13,719.43
|
| Rate for Payer: BCN Commercial |
$13,719.43
|
| Rate for Payer: BCN Medicare Advantage |
$5,450.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,450.88
|
| Rate for Payer: Mclaren Medicare |
$5,450.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,723.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,268.51
|
| Rate for Payer: Molina Medicare/Medicaid |
$5,995.97
|
| Rate for Payer: Nomi Health Commercial |
$8,132.16
|
| Rate for Payer: PACE Medicare |
$5,178.34
|
| Rate for Payer: PACE SWMI |
$5,450.88
|
| Rate for Payer: PHP Medicare Advantage |
$5,450.88
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,163.40
|
| Rate for Payer: Priority Health Medicare |
$5,450.88
|
| Rate for Payer: Priority Health Tiered Network |
$8,130.72
|
| Rate for Payer: Railroad Medicare Medicare |
$5,450.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,275.52
|
| Rate for Payer: UHC Core |
$8,596.76
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5,450.88
|
| Rate for Payer: UHC Exchange |
$7,020.76
|
| Rate for Payer: VA VA |
$5,450.88
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH CC
|
Facility
|
IP
|
$12,873.74
|
|
|
Service Code
|
MSDRG 389
|
| Min. Negotiated Rate |
$6,348.61 |
| Max. Negotiated Rate |
$12,873.74 |
| Rate for Payer: Aetna Medicare |
$6,950.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,353.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,353.44
|
| Rate for Payer: BCBS MAPPO |
$6,682.75
|
| Rate for Payer: BCBS Trust/PPO |
$12,240.04
|
| Rate for Payer: BCN Commercial |
$12,240.04
|
| Rate for Payer: BCN Medicare Advantage |
$6,682.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,682.75
|
| Rate for Payer: Mclaren Medicare |
$6,682.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,016.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,685.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,351.02
|
| Rate for Payer: Nomi Health Commercial |
$10,188.42
|
| Rate for Payer: PACE Medicare |
$6,348.61
|
| Rate for Payer: PACE SWMI |
$6,682.75
|
| Rate for Payer: PHP Medicare Advantage |
$6,682.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$12,733.27
|
| Rate for Payer: Priority Health Medicare |
$6,682.75
|
| Rate for Payer: Priority Health Tiered Network |
$10,186.61
|
| Rate for Payer: Railroad Medicare Medicare |
$6,682.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,873.74
|
| Rate for Payer: UHC Core |
$10,770.50
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,682.75
|
| Rate for Payer: UHC Exchange |
$8,796.00
|
| Rate for Payer: VA VA |
$6,682.75
|
|
|
GASTROINTESTINAL OBSTRUCTION WITH MCC
|
Facility
|
IP
|
$24,071.84
|
|
|
Service Code
|
MSDRG 388
|
| Min. Negotiated Rate |
$11,392.45 |
| Max. Negotiated Rate |
$24,071.84 |
| Rate for Payer: Aetna Medicare |
$12,471.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,990.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,990.06
|
| Rate for Payer: BCBS MAPPO |
$11,992.05
|
| Rate for Payer: BCBS Trust/PPO |
$22,099.49
|
| Rate for Payer: BCN Commercial |
$22,099.49
|
| Rate for Payer: BCN Medicare Advantage |
$11,992.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,992.05
|
| Rate for Payer: Mclaren Medicare |
$11,992.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,591.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,790.86
|
| Rate for Payer: Molina Medicare/Medicaid |
$13,191.25
|
| Rate for Payer: Nomi Health Commercial |
$19,050.72
|
| Rate for Payer: PACE Medicare |
$11,392.45
|
| Rate for Payer: PACE SWMI |
$11,992.05
|
| Rate for Payer: PHP Medicare Advantage |
$11,992.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,809.18
|
| Rate for Payer: Priority Health Medicare |
$11,992.05
|
| Rate for Payer: Priority Health Tiered Network |
$19,047.34
|
| Rate for Payer: Railroad Medicare Medicare |
$11,992.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,071.84
|
| Rate for Payer: UHC Core |
$20,139.12
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$11,992.05
|
| Rate for Payer: UHC Exchange |
$16,447.12
|
| Rate for Payer: VA VA |
$11,992.05
|
|
