|
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC
|
Facility
|
IP
|
$195,391.18
|
|
|
Service Code
|
MS-DRG 016
|
| Min. Negotiated Rate |
$42,729.28 |
| Max. Negotiated Rate |
$195,391.18 |
| Rate for Payer: Aetna Medicare |
$46,777.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$56,222.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$56,222.74
|
| Rate for Payer: BCBS MAPPO |
$44,978.19
|
| Rate for Payer: BCBS Trust/PPO |
$195,391.18
|
| Rate for Payer: BCN Medicare Advantage |
$44,978.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44,978.19
|
| Rate for Payer: Mclaren Medicare |
$44,978.19
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$47,227.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51,724.92
|
| Rate for Payer: PACE Medicare |
$42,729.28
|
| Rate for Payer: PACE SWMI |
$44,978.19
|
| Rate for Payer: PHP Medicare Advantage |
$44,978.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$88,639.46
|
| Rate for Payer: Priority Health Medicare |
$44,978.19
|
| Rate for Payer: Priority Health Narrow Network |
$70,911.57
|
| Rate for Payer: Railroad Medicare Medicare |
$44,978.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$94,223.96
|
| Rate for Payer: UHC Core |
$57,816.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$44,978.19
|
| Rate for Payer: UHC Exchange |
$61,924.43
|
| Rate for Payer: UHC Medicare Advantage |
$46,327.54
|
| Rate for Payer: VA VA |
$44,978.19
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$99,966.15
|
|
|
Service Code
|
MS-DRG 017
|
| Min. Negotiated Rate |
$42,729.28 |
| Max. Negotiated Rate |
$99,966.15 |
| Rate for Payer: Aetna Medicare |
$46,777.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$56,222.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$56,222.74
|
| Rate for Payer: BCBS MAPPO |
$44,978.19
|
| Rate for Payer: BCBS Trust/PPO |
$99,966.15
|
| Rate for Payer: BCN Medicare Advantage |
$44,978.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44,978.19
|
| Rate for Payer: Mclaren Medicare |
$44,978.19
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$47,227.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51,724.92
|
| Rate for Payer: PACE Medicare |
$42,729.28
|
| Rate for Payer: PACE SWMI |
$44,978.19
|
| Rate for Payer: PHP Medicare Advantage |
$44,978.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$88,639.46
|
| Rate for Payer: Priority Health Medicare |
$44,978.19
|
| Rate for Payer: Priority Health Narrow Network |
$70,911.57
|
| Rate for Payer: Railroad Medicare Medicare |
$44,978.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$94,223.96
|
| Rate for Payer: UHC Core |
$57,816.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$44,978.19
|
| Rate for Payer: UHC Exchange |
$61,924.43
|
| Rate for Payer: UHC Medicare Advantage |
$46,327.54
|
| Rate for Payer: VA VA |
$44,978.19
|
|
|
AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 11732
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$16.37 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: BCBS Trust/PPO |
$63.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.01
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$16.37
|
|
|
AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 11730
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$52.39 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: Aetna Medicare |
$185.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.68
|
| Rate for Payer: BCBS Complete |
$102.32
|
| Rate for Payer: BCBS MAPPO |
$178.14
|
| Rate for Payer: BCBS Trust/PPO |
$96.78
|
| Rate for Payer: BCN Medicare Advantage |
$178.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$178.14
|
| Rate for Payer: Mclaren Medicaid |
$97.44
|
| Rate for Payer: Mclaren Medicare |
$178.14
|
| Rate for Payer: Meridian Medicaid |
$102.32
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$187.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.86
|
| Rate for Payer: PACE Medicare |
$169.23
|
| Rate for Payer: PACE SWMI |
$178.14
|
| Rate for Payer: PHP Medicare Advantage |
$178.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$541.49
|
| Rate for Payer: Priority Health Medicare |
$178.14
|
| Rate for Payer: Priority Health Narrow Network |
$433.19
|
| Rate for Payer: Railroad Medicare Medicare |
$178.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.63
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$178.14
|
| Rate for Payer: UHC Exchange |
$52.39
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: VA VA |
$178.14
|
|
|
AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 11730
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$52.39 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: Aetna Medicare |
$185.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.68
|
| Rate for Payer: BCBS Complete |
$102.32
|
| Rate for Payer: BCBS MAPPO |
$178.14
|
| Rate for Payer: BCBS Trust/PPO |
$96.78
|
| Rate for Payer: BCN Medicare Advantage |
$178.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$178.14
|
| Rate for Payer: Mclaren Medicaid |
$97.44
|
| Rate for Payer: Mclaren Medicare |
$178.14
|
| Rate for Payer: Meridian Medicaid |
$102.32
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$187.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.86
|
| Rate for Payer: PACE Medicare |
$169.23
|
| Rate for Payer: PACE SWMI |
$178.14
|
| Rate for Payer: PHP Medicare Advantage |
$178.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$541.49
|
| Rate for Payer: Priority Health Medicare |
$178.14
|
| Rate for Payer: Priority Health Narrow Network |
$433.19
|
| Rate for Payer: Railroad Medicare Medicare |
$178.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.63
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$178.14
|
| Rate for Payer: UHC Exchange |
$52.39
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: VA VA |
$178.14
|
|
|
AXILLARY LYMPHADENECTOMY; COMPLETE
|
Facility
|
OP
|
$15,754.72
|
|
|
Service Code
|
CPT 38745
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$871.65 |
| Max. Negotiated Rate |
$15,754.72 |
| Rate for Payer: Aetna Medicare |
$5,339.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,417.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,417.61
|
| Rate for Payer: BCBS Complete |
$2,949.02
|
| Rate for Payer: BCBS MAPPO |
$5,134.09
|
| Rate for Payer: BCBS Trust/PPO |
$2,064.84
|
| Rate for Payer: BCN Medicare Advantage |
$5,134.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,134.09
|
| Rate for Payer: Mclaren Medicaid |
$2,808.35
|
| Rate for Payer: Mclaren Medicare |
$5,134.09
|
| Rate for Payer: Meridian Medicaid |
$2,949.02
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,390.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,904.20
|
| Rate for Payer: PACE Medicare |
$4,877.39
|
| Rate for Payer: PACE SWMI |
$5,134.09
|
| Rate for Payer: PHP Medicare Advantage |
$5,134.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,808.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,754.72
|
| Rate for Payer: Priority Health Medicare |
$5,134.09
|
| Rate for Payer: Priority Health Narrow Network |
$12,603.78
|
| Rate for Payer: Railroad Medicare Medicare |
$5,134.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$958.82
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,134.09
|
| Rate for Payer: UHC Exchange |
$871.65
|
| Rate for Payer: UHC Medicare Advantage |
$5,288.11
|
| Rate for Payer: VA VA |
$5,134.09
|
|
|
AZACITIDINE 100 MG/10 ML SOLN
|
Facility
|
OP
|
$344.10
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
168892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$309.69 |
| Rate for Payer: Aetna Commercial |
$292.48
|
| Rate for Payer: Aetna Commercial |
$243.70
|
| Rate for Payer: Aetna Commercial |
$389.10
|
| Rate for Payer: Aetna Commercial |
$2,233.57
|
| Rate for Payer: Aetna Commercial |
$312.00
|
| Rate for Payer: Aetna Commercial |
$595.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$455.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,708.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$238.59
|
| Rate for Payer: BCBS Complete |
$114.68
|
| Rate for Payer: BCBS Complete |
$183.11
|
| Rate for Payer: BCBS Complete |
$146.82
|
| Rate for Payer: BCBS Complete |
$1,051.09
|
| Rate for Payer: BCBS Complete |
$137.64
|
| Rate for Payer: BCBS Complete |
$280.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: Cash Price |
$560.26
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cash Price |
$275.28
|
| Rate for Payer: Cash Price |
$275.28
|
| Rate for Payer: Cash Price |
$560.26
|
| Rate for Payer: Cash Price |
$366.22
|
| Rate for Payer: Cash Price |
$293.65
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$293.65
|
| Rate for Payer: Cash Price |
$366.22
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cofinity Commercial |
$320.44
|
| Rate for Payer: Cofinity Commercial |
$256.94
|
| Rate for Payer: Cofinity Commercial |
$240.87
|
| Rate for Payer: Cofinity Commercial |
$295.93
|
| Rate for Payer: Cofinity Commercial |
$1,839.41
|
| Rate for Payer: Cofinity Commercial |
$2,259.85
|
| Rate for Payer: Cofinity Commercial |
$200.69
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Cofinity Commercial |
$393.68
|
| Rate for Payer: Cofinity Commercial |
$315.67
|
| Rate for Payer: Cofinity Commercial |
$490.22
|
| Rate for Payer: Cofinity Commercial |
$602.28
|
| Rate for Payer: Healthscope Commercial |
$2,364.96
|
| Rate for Payer: Healthscope Commercial |
$330.35
|
| Rate for Payer: Healthscope Commercial |
$411.99
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Healthscope Commercial |
$630.29
|
| Rate for Payer: Healthscope Commercial |
$309.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$389.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,233.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$243.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$292.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$312.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$595.27
|
| Rate for Payer: PHP Commercial |
$389.10
|
| Rate for Payer: PHP Commercial |
$292.48
|
| Rate for Payer: PHP Commercial |
$243.70
|
| Rate for Payer: PHP Commercial |
$312.00
|
| Rate for Payer: PHP Commercial |
$595.27
|
| Rate for Payer: PHP Commercial |
$2,233.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$320.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$240.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,839.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$490.22
|
| Rate for Payer: Priority Health SBD |
$180.62
|
| Rate for Payer: Priority Health SBD |
$216.78
|
| Rate for Payer: Priority Health SBD |
$1,655.47
|
| Rate for Payer: Priority Health SBD |
$288.40
|
| Rate for Payer: Priority Health SBD |
$231.25
|
| Rate for Payer: Priority Health SBD |
$441.20
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$2,627.73
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
78420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,655.47 |
| Max. Negotiated Rate |
$2,364.96 |
| Rate for Payer: Aetna Commercial |
$2,233.57
|
| Rate for Payer: Aetna Commercial |
$312.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$238.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,708.02
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$293.65
|
| Rate for Payer: Cofinity Commercial |
$256.94
|
| Rate for Payer: Cofinity Commercial |
$1,839.41
|
| Rate for Payer: Cofinity Commercial |
$2,259.85
|
| Rate for Payer: Cofinity Commercial |
$315.67
|
| Rate for Payer: Healthscope Commercial |
$2,364.96
|
| Rate for Payer: Healthscope Commercial |
$330.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$312.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,233.57
|
| Rate for Payer: PHP Commercial |
$312.00
|
| Rate for Payer: PHP Commercial |
$2,233.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,839.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.94
|
| Rate for Payer: Priority Health SBD |
$1,655.47
|
| Rate for Payer: Priority Health SBD |
$231.25
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$344.10
|
|
|
Service Code
|
HCPCS J9025
|
| Hospital Charge Code |
78420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$309.69 |
| Rate for Payer: Aetna Commercial |
$292.48
|
| Rate for Payer: Aetna Commercial |
$595.27
|
| Rate for Payer: Aetna Commercial |
$2,233.57
|
| Rate for Payer: Aetna Commercial |
$389.10
|
| Rate for Payer: Aetna Commercial |
$312.00
|
| Rate for Payer: Aetna Commercial |
$243.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$455.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$238.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,708.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.55
|
| Rate for Payer: BCBS Complete |
$137.64
|
| Rate for Payer: BCBS Complete |
$1,051.09
|
| Rate for Payer: BCBS Complete |
$114.68
|
| Rate for Payer: BCBS Complete |
$146.82
|
| Rate for Payer: BCBS Complete |
$183.11
|
| Rate for Payer: BCBS Complete |
$280.13
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: BCBS Trust/PPO |
$1.02
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cash Price |
$366.22
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$275.28
|
| Rate for Payer: Cash Price |
$2,102.18
|
| Rate for Payer: Cash Price |
$366.22
|
| Rate for Payer: Cash Price |
$275.28
|
| Rate for Payer: Cash Price |
$560.26
|
| Rate for Payer: Cash Price |
$229.36
|
| Rate for Payer: Cash Price |
$293.65
|
| Rate for Payer: Cash Price |
$560.26
|
| Rate for Payer: Cash Price |
$293.65
|
| Rate for Payer: Cofinity Commercial |
$200.69
|
| Rate for Payer: Cofinity Commercial |
$490.22
|
| Rate for Payer: Cofinity Commercial |
$240.87
|
| Rate for Payer: Cofinity Commercial |
$295.93
|
| Rate for Payer: Cofinity Commercial |
$246.56
|
| Rate for Payer: Cofinity Commercial |
$2,259.85
|
| Rate for Payer: Cofinity Commercial |
$256.94
|
| Rate for Payer: Cofinity Commercial |
$315.67
|
| Rate for Payer: Cofinity Commercial |
$1,839.41
|
| Rate for Payer: Cofinity Commercial |
$320.44
|
| Rate for Payer: Cofinity Commercial |
$393.68
|
| Rate for Payer: Cofinity Commercial |
$602.28
|
| Rate for Payer: Healthscope Commercial |
$411.99
|
| Rate for Payer: Healthscope Commercial |
$330.35
|
| Rate for Payer: Healthscope Commercial |
$630.29
|
| Rate for Payer: Healthscope Commercial |
$2,364.96
|
| Rate for Payer: Healthscope Commercial |
$258.03
|
| Rate for Payer: Healthscope Commercial |
$309.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$312.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$595.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$292.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,233.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$243.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$389.10
|
| Rate for Payer: PHP Commercial |
$243.70
|
| Rate for Payer: PHP Commercial |
$595.27
|
| Rate for Payer: PHP Commercial |
$292.48
|
| Rate for Payer: PHP Commercial |
$389.10
|
| Rate for Payer: PHP Commercial |
$312.00
|
| Rate for Payer: PHP Commercial |
$2,233.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,839.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$240.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$320.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$490.22
|
| Rate for Payer: Priority Health SBD |
$288.40
|
| Rate for Payer: Priority Health SBD |
$1,655.47
|
| Rate for Payer: Priority Health SBD |
$231.25
|
| Rate for Payer: Priority Health SBD |
$180.62
|
| Rate for Payer: Priority Health SBD |
$216.78
|
| Rate for Payer: Priority Health SBD |
$441.20
|
|
|
AZATHIOPRINE 50 MG TABLET
|
Facility
|
IP
|
$255.36
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
9183
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$160.88 |
| Max. Negotiated Rate |
$229.82 |
| Rate for Payer: Aetna Commercial |
$217.06
|
| Rate for Payer: Aetna Commercial |
$348.84
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.76
|
| Rate for Payer: Cash Price |
$328.32
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cash Price |
$204.29
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$352.94
|
| Rate for Payer: Cofinity Commercial |
$178.75
|
| Rate for Payer: Cofinity Commercial |
$219.61
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Commercial |
$278.64
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Cofinity Commercial |
$287.28
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Healthscope Commercial |
$369.36
|
| Rate for Payer: Healthscope Commercial |
$229.82
|
| Rate for Payer: Healthscope Commercial |
$358.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$338.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$348.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.06
|
| Rate for Payer: PHP Commercial |
$217.06
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$348.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.64
|
| Rate for Payer: Priority Health SBD |
$250.77
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: Priority Health SBD |
$160.88
|
| Rate for Payer: Priority Health SBD |
$258.55
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$116.79
|
|
|
Service Code
|
NDC 0093-2026-31
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.58 |
| Max. Negotiated Rate |
$105.11 |
| Rate for Payer: Aetna Commercial |
$99.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.91
|
| Rate for Payer: Cash Price |
$93.43
|
| Rate for Payer: Cofinity Commercial |
$100.44
|
| Rate for Payer: Cofinity Commercial |
$81.75
|
| Rate for Payer: Healthscope Commercial |
$105.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.27
|
| Rate for Payer: PHP Commercial |
$99.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.75
|
| Rate for Payer: Priority Health SBD |
$73.58
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$124.55
|
|
|
Service Code
|
NDC 70710-1460-2
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.47 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Aetna Commercial |
$105.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.96
|
| Rate for Payer: Cash Price |
$99.64
|
| Rate for Payer: Cofinity Commercial |
$107.11
|
| Rate for Payer: Cofinity Commercial |
$87.18
|
| Rate for Payer: Healthscope Commercial |
$112.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$105.87
|
| Rate for Payer: PHP Commercial |
$105.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.18
|
| Rate for Payer: Priority Health SBD |
$78.47
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$89.28
|
|
|
Service Code
|
NDC 59762-3140-1
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.25 |
| Max. Negotiated Rate |
$80.35 |
| Rate for Payer: Aetna Commercial |
$75.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.03
|
| Rate for Payer: Cash Price |
$71.42
|
| Rate for Payer: Cofinity Commercial |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$76.78
|
| Rate for Payer: Healthscope Commercial |
$80.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.89
|
| Rate for Payer: PHP Commercial |
$75.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.50
|
| Rate for Payer: Priority Health SBD |
$56.25
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$94.05
|
|
|
Service Code
|
NDC 42806-151-34
|
| Hospital Charge Code |
15797
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.25 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$79.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.13
|
| Rate for Payer: Cash Price |
$75.24
|
| Rate for Payer: Cofinity Commercial |
$65.84
|
| Rate for Payer: Cofinity Commercial |
$80.88
|
| Rate for Payer: Healthscope Commercial |
$84.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.94
|
| Rate for Payer: PHP Commercial |
$79.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.84
|
| Rate for Payer: Priority Health SBD |
$59.25
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
NDC 50268-098-11
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.68
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.65
|
| Rate for Payer: PHP Commercial |
$2.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.18
|
| Rate for Payer: Priority Health SBD |
$1.97
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$513.60
|
|
|
Service Code
|
NDC 0904-7350-61
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$323.57 |
| Max. Negotiated Rate |
$462.24 |
| Rate for Payer: Aetna Commercial |
$436.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$333.84
|
| Rate for Payer: Cash Price |
$410.88
|
| Rate for Payer: Cofinity Commercial |
$359.52
|
| Rate for Payer: Cofinity Commercial |
$441.70
|
| Rate for Payer: Healthscope Commercial |
$462.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$436.56
|
| Rate for Payer: PHP Commercial |
$436.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$359.52
|
| Rate for Payer: Priority Health SBD |
$323.57
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$775.20
|
|
|
Service Code
|
NDC 60687-282-01
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$488.38 |
| Max. Negotiated Rate |
$697.68 |
| Rate for Payer: Aetna Commercial |
$658.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.88
|
| Rate for Payer: Cash Price |
$620.16
|
| Rate for Payer: Cofinity Commercial |
$542.64
|
| Rate for Payer: Cofinity Commercial |
$666.67
|
| Rate for Payer: Healthscope Commercial |
$697.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$658.92
|
| Rate for Payer: PHP Commercial |
$658.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$542.64
|
| Rate for Payer: Priority Health SBD |
$488.38
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$231.12
|
|
|
Service Code
|
NDC 50268-098-15
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.61 |
| Max. Negotiated Rate |
$208.01 |
| Rate for Payer: Aetna Commercial |
$196.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.23
|
| Rate for Payer: Cash Price |
$184.90
|
| Rate for Payer: Cofinity Commercial |
$161.78
|
| Rate for Payer: Cofinity Commercial |
$198.76
|
| Rate for Payer: Healthscope Commercial |
$208.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$196.45
|
| Rate for Payer: PHP Commercial |
$196.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.78
|
| Rate for Payer: Priority Health SBD |
$145.61
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$59.57
|
|
|
Service Code
|
NDC 59762-2198-7
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.53 |
| Max. Negotiated Rate |
$53.61 |
| Rate for Payer: Aetna Commercial |
$50.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.72
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Cofinity Commercial |
$41.70
|
| Rate for Payer: Cofinity Commercial |
$51.23
|
| Rate for Payer: Healthscope Commercial |
$53.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.63
|
| Rate for Payer: PHP Commercial |
$50.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.70
|
| Rate for Payer: Priority Health SBD |
$37.53
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$154.08
|
|
|
Service Code
|
NDC 0904-6708-06
|
| Hospital Charge Code |
20943
|
|
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 Commercial |
$107.86
|
| Rate for Payer: Cofinity Commercial |
$132.51
|
| Rate for Payer: Healthscope Commercial |
$138.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.97
|
| Rate for Payer: PHP Commercial |
$130.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.86
|
| Rate for Payer: Priority Health SBD |
$97.07
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$281.96
|
|
|
Service Code
|
NDC 64679-961-01
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.63 |
| Max. Negotiated Rate |
$253.76 |
| Rate for Payer: Aetna Commercial |
$239.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.27
|
| Rate for Payer: Cash Price |
$225.57
|
| Rate for Payer: Cofinity Commercial |
$197.37
|
| Rate for Payer: Cofinity Commercial |
$242.49
|
| Rate for Payer: Healthscope Commercial |
$253.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.67
|
| Rate for Payer: PHP Commercial |
$239.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.37
|
| Rate for Payer: Priority Health SBD |
$177.63
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$409.92
|
|
|
Service Code
|
NDC 0904-6708-61
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.25 |
| Max. Negotiated Rate |
$368.93 |
| Rate for Payer: Aetna Commercial |
$348.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.45
|
| Rate for Payer: Cash Price |
$327.94
|
| Rate for Payer: Cofinity Commercial |
$286.94
|
| Rate for Payer: Cofinity Commercial |
$352.53
|
| Rate for Payer: Healthscope Commercial |
$368.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$348.43
|
| Rate for Payer: PHP Commercial |
$348.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.94
|
| Rate for Payer: Priority Health SBD |
$258.25
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$154.32
|
|
|
Service Code
|
NDC 0904-7350-06
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.22 |
| Max. Negotiated Rate |
$138.89 |
| Rate for Payer: Aetna Commercial |
$131.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.31
|
| Rate for Payer: Cash Price |
$123.46
|
| Rate for Payer: Cofinity Commercial |
$108.02
|
| Rate for Payer: Cofinity Commercial |
$132.72
|
| Rate for Payer: Healthscope Commercial |
$138.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$131.17
|
| Rate for Payer: PHP Commercial |
$131.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.02
|
| Rate for Payer: Priority Health SBD |
$97.22
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$155.76
|
|
|
Service Code
|
NDC 50268-074-15
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.13 |
| Max. Negotiated Rate |
$140.18 |
| Rate for Payer: Aetna Commercial |
$132.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.24
|
| Rate for Payer: Cash Price |
$124.61
|
| Rate for Payer: Cofinity Commercial |
$109.03
|
| Rate for Payer: Cofinity Commercial |
$133.95
|
| Rate for Payer: Healthscope Commercial |
$140.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$132.40
|
| Rate for Payer: PHP Commercial |
$132.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.03
|
| Rate for Payer: Priority Health SBD |
$98.13
|
|
|
AZITHROMYCIN 250 MG TABLET
|
Facility
|
IP
|
$137.66
|
|
|
Service Code
|
NDC 0781-8089-31
|
| Hospital Charge Code |
20943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.73 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$117.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.48
|
| Rate for Payer: Cash Price |
$110.13
|
| Rate for Payer: Cofinity Commercial |
$118.39
|
| Rate for Payer: Cofinity Commercial |
$96.36
|
| Rate for Payer: Healthscope Commercial |
$123.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$117.01
|
| Rate for Payer: PHP Commercial |
$117.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.36
|
| Rate for Payer: Priority Health SBD |
$86.73
|
|
