|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$158.59
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.44 |
| Max. Negotiated Rate |
$142.73 |
| Rate for Payer: Aetna Commercial |
$134.80
|
| Rate for Payer: Aetna Medicare |
$79.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.08
|
| Rate for Payer: BCBS Complete |
$63.44
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cofinity Commercial |
$111.01
|
| Rate for Payer: Cofinity Commercial |
$136.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.87
|
| Rate for Payer: Healthscope Commercial |
$142.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.80
|
| Rate for Payer: PHP Commercial |
$134.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.08
|
| Rate for Payer: Priority Health SBD |
$99.91
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,934.31
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$2,640.88 |
| Rate for Payer: Aetna Commercial |
$2,494.16
|
| Rate for Payer: Aetna Commercial |
$1,290.10
|
| Rate for Payer: Aetna Medicare |
$6.53
|
| Rate for Payer: Aetna Medicare |
$6.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,907.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$986.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.85
|
| Rate for Payer: BCBS Complete |
$3.53
|
| Rate for Payer: BCBS Complete |
$3.53
|
| Rate for Payer: BCBS MAPPO |
$6.28
|
| Rate for Payer: BCBS MAPPO |
$6.28
|
| Rate for Payer: BCN Medicare Advantage |
$6.28
|
| Rate for Payer: BCN Medicare Advantage |
$6.28
|
| Rate for Payer: Cash Price |
$1,214.21
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cash Price |
$1,214.21
|
| Rate for Payer: Cofinity Commercial |
$1,305.27
|
| Rate for Payer: Cofinity Commercial |
$2,523.51
|
| Rate for Payer: Cofinity Commercial |
$2,054.02
|
| Rate for Payer: Cofinity Commercial |
$1,062.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,062.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,054.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,214.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,347.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.28
|
| Rate for Payer: Healthscope Commercial |
$2,640.88
|
| Rate for Payer: Healthscope Commercial |
$1,365.98
|
| Rate for Payer: Mclaren Medicaid |
$3.37
|
| Rate for Payer: Mclaren Medicaid |
$3.37
|
| Rate for Payer: Mclaren Medicare |
$6.28
|
| Rate for Payer: Mclaren Medicare |
$6.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.59
|
| Rate for Payer: Meridian Medicaid |
$3.53
|
| Rate for Payer: Meridian Medicaid |
$3.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,494.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,290.10
|
| Rate for Payer: PACE Medicare |
$5.97
|
| Rate for Payer: PACE Medicare |
$5.97
|
| Rate for Payer: PACE SWMI |
$6.28
|
| Rate for Payer: PACE SWMI |
$6.28
|
| Rate for Payer: PHP Commercial |
$2,494.16
|
| Rate for Payer: PHP Commercial |
$1,290.10
|
| Rate for Payer: PHP Medicare Advantage |
$6.28
|
| Rate for Payer: PHP Medicare Advantage |
$6.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,907.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$986.54
|
| Rate for Payer: Priority Health Medicare |
$6.28
|
| Rate for Payer: Priority Health Medicare |
$6.28
|
| Rate for Payer: Priority Health SBD |
$956.19
|
| Rate for Payer: Priority Health SBD |
$1,848.62
|
| Rate for Payer: Railroad Medicare Medicare |
$6.28
|
| Rate for Payer: Railroad Medicare Medicare |
$6.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.28
|
| Rate for Payer: UHC Medicare Advantage |
$6.28
|
| Rate for Payer: UHC Medicare Advantage |
$6.28
|
| Rate for Payer: UHCCP Medicaid |
$3.54
|
| Rate for Payer: UHCCP Medicaid |
$3.54
|
| Rate for Payer: VA VA |
$6.28
|
| Rate for Payer: VA VA |
$6.28
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,517.76
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$956.19 |
| Max. Negotiated Rate |
$1,365.98 |
| Rate for Payer: Aetna Commercial |
$1,290.10
|
| Rate for Payer: Aetna Commercial |
$2,494.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$986.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,907.30
|
| Rate for Payer: Cash Price |
$1,214.21
|
| Rate for Payer: Cash Price |
$2,347.45
|
| Rate for Payer: Cofinity Commercial |
$1,062.43
|
| Rate for Payer: Cofinity Commercial |
$2,054.02
|
| Rate for Payer: Cofinity Commercial |
$2,523.51
|
| Rate for Payer: Cofinity Commercial |
$1,305.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,054.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,062.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,214.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,347.45
|
| Rate for Payer: Healthscope Commercial |
$1,365.98
|
| Rate for Payer: Healthscope Commercial |
$2,640.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,494.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,290.10
|
| Rate for Payer: PHP Commercial |
$1,290.10
|
| Rate for Payer: PHP Commercial |
$2,494.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,907.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$986.54
|
| Rate for Payer: Priority Health SBD |
$956.19
|
| Rate for Payer: Priority Health SBD |
$1,848.62
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$166.75
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
115590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.05 |
| Max. Negotiated Rate |
$150.07 |
| Rate for Payer: Aetna Commercial |
$141.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.39
|
| Rate for Payer: Cash Price |
$133.40
|
| Rate for Payer: Cofinity Commercial |
$116.72
|
| Rate for Payer: Cofinity Commercial |
$143.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.40
|
| Rate for Payer: Healthscope Commercial |
$150.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.74
|
| Rate for Payer: PHP Commercial |
$141.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.39
|
| Rate for Payer: Priority Health SBD |
$105.05
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$166.75
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
115590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.70 |
| Max. Negotiated Rate |
$150.07 |
| Rate for Payer: Aetna Commercial |
$141.74
|
| Rate for Payer: Aetna Medicare |
$83.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.39
|
| Rate for Payer: BCBS Complete |
$66.70
|
| Rate for Payer: Cash Price |
$133.40
|
| Rate for Payer: Cofinity Commercial |
$116.72
|
| Rate for Payer: Cofinity Commercial |
$143.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.40
|
| Rate for Payer: Healthscope Commercial |
$150.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.74
|
| Rate for Payer: PHP Commercial |
$141.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.39
|
| Rate for Payer: Priority Health SBD |
$105.05
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$25.28
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Commercial |
$21.49
|
| Rate for Payer: Aetna Commercial |
$43.10
|
| Rate for Payer: Aetna Commercial |
$27.99
|
| Rate for Payer: Aetna Medicare |
$25.36
|
| Rate for Payer: Aetna Medicare |
$12.64
|
| Rate for Payer: Aetna Medicare |
$16.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.40
|
| Rate for Payer: BCBS Complete |
$13.17
|
| Rate for Payer: BCBS Complete |
$10.11
|
| Rate for Payer: BCBS Complete |
$20.28
|
| Rate for Payer: Cash Price |
$40.57
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cash Price |
$26.34
|
| Rate for Payer: Cofinity Commercial |
$43.61
|
| Rate for Payer: Cofinity Commercial |
$21.74
|
| Rate for Payer: Cofinity Commercial |
$17.70
|
| Rate for Payer: Cofinity Commercial |
$28.32
|
| Rate for Payer: Cofinity Commercial |
$23.05
|
| Rate for Payer: Cofinity Commercial |
$35.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.22
|
| Rate for Payer: Healthscope Commercial |
$29.64
|
| Rate for Payer: Healthscope Commercial |
$22.75
|
| Rate for Payer: Healthscope Commercial |
$45.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.49
|
| Rate for Payer: PHP Commercial |
$27.99
|
| Rate for Payer: PHP Commercial |
$21.49
|
| Rate for Payer: PHP Commercial |
$43.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.40
|
| Rate for Payer: Priority Health SBD |
$31.95
|
| Rate for Payer: Priority Health SBD |
$20.75
|
| Rate for Payer: Priority Health SBD |
$15.93
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$32.93
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$29.64 |
| Rate for Payer: Aetna Commercial |
$27.99
|
| Rate for Payer: Aetna Commercial |
$21.49
|
| Rate for Payer: Aetna Commercial |
$43.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.40
|
| Rate for Payer: Cash Price |
$26.34
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cash Price |
$40.57
|
| Rate for Payer: Cofinity Commercial |
$35.50
|
| Rate for Payer: Cofinity Commercial |
$43.61
|
| Rate for Payer: Cofinity Commercial |
$28.32
|
| Rate for Payer: Cofinity Commercial |
$21.74
|
| Rate for Payer: Cofinity Commercial |
$17.70
|
| Rate for Payer: Cofinity Commercial |
$23.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.57
|
| Rate for Payer: Healthscope Commercial |
$22.75
|
| Rate for Payer: Healthscope Commercial |
$29.64
|
| Rate for Payer: Healthscope Commercial |
$45.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.10
|
| Rate for Payer: PHP Commercial |
$21.49
|
| Rate for Payer: PHP Commercial |
$27.99
|
| Rate for Payer: PHP Commercial |
$43.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.96
|
| Rate for Payer: Priority Health SBD |
$31.95
|
| Rate for Payer: Priority Health SBD |
$15.93
|
| Rate for Payer: Priority Health SBD |
$20.75
|
|
|
FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$82.31
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
115589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.92 |
| Max. Negotiated Rate |
$74.08 |
| Rate for Payer: Aetna Commercial |
$69.96
|
| Rate for Payer: Aetna Commercial |
$55.94
|
| Rate for Payer: Aetna Medicare |
$32.91
|
| Rate for Payer: Aetna Medicare |
$41.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.50
|
| Rate for Payer: BCBS Complete |
$32.92
|
| Rate for Payer: BCBS Complete |
$26.32
|
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Cash Price |
$65.85
|
| Rate for Payer: Cofinity Commercial |
$46.07
|
| Rate for Payer: Cofinity Commercial |
$57.62
|
| Rate for Payer: Cofinity Commercial |
$70.79
|
| Rate for Payer: Cofinity Commercial |
$56.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.85
|
| Rate for Payer: Healthscope Commercial |
$59.23
|
| Rate for Payer: Healthscope Commercial |
$74.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.96
|
| Rate for Payer: PHP Commercial |
$69.96
|
| Rate for Payer: PHP Commercial |
$55.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.50
|
| Rate for Payer: Priority Health SBD |
$51.86
|
| Rate for Payer: Priority Health SBD |
$41.46
|
|
|
FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$82.31
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
115589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.86 |
| Max. Negotiated Rate |
$74.08 |
| Rate for Payer: Aetna Commercial |
$69.96
|
| Rate for Payer: Aetna Commercial |
$55.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.50
|
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Cash Price |
$65.85
|
| Rate for Payer: Cofinity Commercial |
$46.07
|
| Rate for Payer: Cofinity Commercial |
$57.62
|
| Rate for Payer: Cofinity Commercial |
$70.79
|
| Rate for Payer: Cofinity Commercial |
$56.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.85
|
| Rate for Payer: Healthscope Commercial |
$59.23
|
| Rate for Payer: Healthscope Commercial |
$74.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.96
|
| Rate for Payer: PHP Commercial |
$55.94
|
| Rate for Payer: PHP Commercial |
$69.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.78
|
| Rate for Payer: Priority Health SBD |
$51.86
|
| Rate for Payer: Priority Health SBD |
$41.46
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$192.81
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
39803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.47 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Aetna Commercial |
$163.89
|
| Rate for Payer: Aetna Commercial |
$108.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.33
|
| Rate for Payer: Cash Price |
$102.23
|
| Rate for Payer: Cash Price |
$154.25
|
| Rate for Payer: Cofinity Commercial |
$165.82
|
| Rate for Payer: Cofinity Commercial |
$134.97
|
| Rate for Payer: Cofinity Commercial |
$109.90
|
| Rate for Payer: Cofinity Commercial |
$89.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$89.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.25
|
| Rate for Payer: Healthscope Commercial |
$173.53
|
| Rate for Payer: Healthscope Commercial |
$115.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.89
|
| Rate for Payer: PHP Commercial |
$163.89
|
| Rate for Payer: PHP Commercial |
$108.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.33
|
| Rate for Payer: Priority Health SBD |
$80.51
|
| Rate for Payer: Priority Health SBD |
$121.47
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
OP
|
$192.81
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
39803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.12 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Aetna Commercial |
$163.89
|
| Rate for Payer: Aetna Commercial |
$108.62
|
| Rate for Payer: Aetna Medicare |
$63.90
|
| Rate for Payer: Aetna Medicare |
$96.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.06
|
| Rate for Payer: BCBS Complete |
$77.12
|
| Rate for Payer: BCBS Complete |
$51.12
|
| Rate for Payer: Cash Price |
$154.25
|
| Rate for Payer: Cash Price |
$102.23
|
| Rate for Payer: Cofinity Commercial |
$165.82
|
| Rate for Payer: Cofinity Commercial |
$109.90
|
| Rate for Payer: Cofinity Commercial |
$89.45
|
| Rate for Payer: Cofinity Commercial |
$134.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$89.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.25
|
| Rate for Payer: Healthscope Commercial |
$173.53
|
| Rate for Payer: Healthscope Commercial |
$115.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.62
|
| Rate for Payer: PHP Commercial |
$163.89
|
| Rate for Payer: PHP Commercial |
$108.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.33
|
| Rate for Payer: Priority Health SBD |
$80.51
|
| Rate for Payer: Priority Health SBD |
$121.47
|
|
|
FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL PATTERN FLAP, PARAMEDIAN FOREHEAD FLAP)
|
Facility
|
OP
|
$10,050.52
|
|
|
Service Code
|
CPT 15731
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,913.77 |
| Max. Negotiated Rate |
$10,050.52 |
| Rate for Payer: Aetna Medicare |
$3,713.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,463.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,463.09
|
| Rate for Payer: BCBS Complete |
$2,009.46
|
| Rate for Payer: BCBS MAPPO |
$3,570.47
|
| Rate for Payer: BCN Medicare Advantage |
$3,570.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,570.47
|
| Rate for Payer: Mclaren Medicaid |
$1,913.77
|
| Rate for Payer: Mclaren Medicare |
$3,570.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,748.99
|
| Rate for Payer: Meridian Medicaid |
$2,009.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,106.04
|
| Rate for Payer: PACE Medicare |
$3,391.95
|
| Rate for Payer: PACE SWMI |
$3,570.47
|
| Rate for Payer: PHP Medicare Advantage |
$3,570.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,913.77
|
| Rate for Payer: Priority Health Medicare |
$3,570.47
|
| Rate for Payer: Railroad Medicare Medicare |
$3,570.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,050.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,570.47
|
| Rate for Payer: UHC Medicare Advantage |
$3,570.47
|
| Rate for Payer: UHCCP Medicaid |
$2,010.17
|
| Rate for Payer: VA VA |
$3,570.47
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION
|
Facility
|
OP
|
$16.98
|
|
|
Service Code
|
HCPCS J7606
|
| Hospital Charge Code |
88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Aetna Commercial |
$14.43
|
| Rate for Payer: Aetna Medicare |
$8.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.04
|
| Rate for Payer: BCBS Complete |
$6.79
|
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Cofinity Commercial |
$11.89
|
| Rate for Payer: Cofinity Commercial |
$14.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.58
|
| Rate for Payer: Healthscope Commercial |
$15.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.43
|
| Rate for Payer: PHP Commercial |
$14.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.04
|
| Rate for Payer: Priority Health SBD |
$10.70
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION
|
Facility
|
IP
|
$16.98
|
|
|
Service Code
|
HCPCS J7606
|
| Hospital Charge Code |
88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.70 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Aetna Commercial |
$14.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.04
|
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Cofinity Commercial |
$11.89
|
| Rate for Payer: Cofinity Commercial |
$14.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.58
|
| Rate for Payer: Healthscope Commercial |
$15.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.43
|
| Rate for Payer: PHP Commercial |
$14.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.04
|
| Rate for Payer: Priority Health SBD |
$10.70
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$1,478.01
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
106783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$931.15 |
| Max. Negotiated Rate |
$1,330.21 |
| Rate for Payer: Aetna Commercial |
$1,256.31
|
| Rate for Payer: Aetna Commercial |
$159.49
|
| Rate for Payer: Aetna Commercial |
$181.59
|
| Rate for Payer: Aetna Commercial |
$364.53
|
| Rate for Payer: Aetna Commercial |
$442.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$960.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$338.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.96
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$150.10
|
| Rate for Payer: Cash Price |
$343.09
|
| Rate for Payer: Cash Price |
$170.90
|
| Rate for Payer: Cash Price |
$1,182.41
|
| Rate for Payer: Cofinity Commercial |
$131.34
|
| Rate for Payer: Cofinity Commercial |
$1,034.61
|
| Rate for Payer: Cofinity Commercial |
$1,271.09
|
| Rate for Payer: Cofinity Commercial |
$447.63
|
| Rate for Payer: Cofinity Commercial |
$364.35
|
| Rate for Payer: Cofinity Commercial |
$161.36
|
| Rate for Payer: Cofinity Commercial |
$368.82
|
| Rate for Payer: Cofinity Commercial |
$300.20
|
| Rate for Payer: Cofinity Commercial |
$149.54
|
| Rate for Payer: Cofinity Commercial |
$183.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$364.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,034.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$149.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$300.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,182.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$416.40
|
| Rate for Payer: Healthscope Commercial |
$192.27
|
| Rate for Payer: Healthscope Commercial |
$168.87
|
| Rate for Payer: Healthscope Commercial |
$1,330.21
|
| Rate for Payer: Healthscope Commercial |
$385.97
|
| Rate for Payer: Healthscope Commercial |
$468.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$442.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,256.31
|
| Rate for Payer: PHP Commercial |
$364.53
|
| Rate for Payer: PHP Commercial |
$442.43
|
| Rate for Payer: PHP Commercial |
$181.59
|
| Rate for Payer: PHP Commercial |
$159.49
|
| Rate for Payer: PHP Commercial |
$1,256.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$960.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$338.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.76
|
| Rate for Payer: Priority Health SBD |
$270.18
|
| Rate for Payer: Priority Health SBD |
$118.21
|
| Rate for Payer: Priority Health SBD |
$134.59
|
| Rate for Payer: Priority Health SBD |
$931.15
|
| Rate for Payer: Priority Health SBD |
$327.92
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$1,478.01
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
106783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$591.20 |
| Max. Negotiated Rate |
$1,330.21 |
| Rate for Payer: Aetna Commercial |
$1,256.31
|
| Rate for Payer: Aetna Commercial |
$159.49
|
| Rate for Payer: Aetna Commercial |
$181.59
|
| Rate for Payer: Aetna Commercial |
$217.39
|
| Rate for Payer: Aetna Commercial |
$442.43
|
| Rate for Payer: Aetna Commercial |
$320.10
|
| Rate for Payer: Aetna Commercial |
$364.53
|
| Rate for Payer: Aetna Medicare |
$127.88
|
| Rate for Payer: Aetna Medicare |
$106.81
|
| Rate for Payer: Aetna Medicare |
$260.25
|
| Rate for Payer: Aetna Medicare |
$188.29
|
| Rate for Payer: Aetna Medicare |
$93.81
|
| Rate for Payer: Aetna Medicare |
$739.00
|
| Rate for Payer: Aetna Medicare |
$214.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$338.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$244.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$960.71
|
| Rate for Payer: BCBS Complete |
$171.54
|
| Rate for Payer: BCBS Complete |
$75.05
|
| Rate for Payer: BCBS Complete |
$102.30
|
| Rate for Payer: BCBS Complete |
$85.45
|
| Rate for Payer: BCBS Complete |
$591.20
|
| Rate for Payer: BCBS Complete |
$150.64
|
| Rate for Payer: BCBS Complete |
$208.20
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$1,182.41
|
| Rate for Payer: Cash Price |
$170.90
|
| Rate for Payer: Cash Price |
$301.27
|
| Rate for Payer: Cash Price |
$150.10
|
| Rate for Payer: Cash Price |
$343.09
|
| Rate for Payer: Cofinity Commercial |
$149.54
|
| Rate for Payer: Cofinity Commercial |
$183.72
|
| Rate for Payer: Cofinity Commercial |
$179.03
|
| Rate for Payer: Cofinity Commercial |
$1,271.09
|
| Rate for Payer: Cofinity Commercial |
$447.63
|
| Rate for Payer: Cofinity Commercial |
$364.35
|
| Rate for Payer: Cofinity Commercial |
$368.82
|
| Rate for Payer: Cofinity Commercial |
$300.20
|
| Rate for Payer: Cofinity Commercial |
$219.94
|
| Rate for Payer: Cofinity Commercial |
$1,034.61
|
| Rate for Payer: Cofinity Commercial |
$263.61
|
| Rate for Payer: Cofinity Commercial |
$323.87
|
| Rate for Payer: Cofinity Commercial |
$161.36
|
| Rate for Payer: Cofinity Commercial |
$131.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$149.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,034.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$263.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$300.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$364.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$301.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$416.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,182.41
|
| Rate for Payer: Healthscope Commercial |
$230.18
|
| Rate for Payer: Healthscope Commercial |
$1,330.21
|
| Rate for Payer: Healthscope Commercial |
$168.87
|
| Rate for Payer: Healthscope Commercial |
$338.93
|
| Rate for Payer: Healthscope Commercial |
$385.97
|
| Rate for Payer: Healthscope Commercial |
$192.27
|
| Rate for Payer: Healthscope Commercial |
$468.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$320.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$442.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,256.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.39
|
| Rate for Payer: PHP Commercial |
$1,256.31
|
| Rate for Payer: PHP Commercial |
$320.10
|
| Rate for Payer: PHP Commercial |
$181.59
|
| Rate for Payer: PHP Commercial |
$364.53
|
| Rate for Payer: PHP Commercial |
$442.43
|
| Rate for Payer: PHP Commercial |
$159.49
|
| Rate for Payer: PHP Commercial |
$217.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$338.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$960.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$244.78
|
| Rate for Payer: Priority Health SBD |
$270.18
|
| Rate for Payer: Priority Health SBD |
$134.59
|
| Rate for Payer: Priority Health SBD |
$327.92
|
| Rate for Payer: Priority Health SBD |
$161.12
|
| Rate for Payer: Priority Health SBD |
$118.21
|
| Rate for Payer: Priority Health SBD |
$931.15
|
| Rate for Payer: Priority Health SBD |
$237.25
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$241.84
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.36 |
| Max. Negotiated Rate |
$217.66 |
| Rate for Payer: Aetna Commercial |
$205.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.20
|
| Rate for Payer: Cash Price |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$169.29
|
| Rate for Payer: Cofinity Commercial |
$207.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$169.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.47
|
| Rate for Payer: Healthscope Commercial |
$217.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.56
|
| Rate for Payer: PHP Commercial |
$205.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.20
|
| Rate for Payer: Priority Health SBD |
$152.36
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$241.84
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.74 |
| Max. Negotiated Rate |
$217.66 |
| Rate for Payer: Aetna Commercial |
$205.56
|
| Rate for Payer: Aetna Medicare |
$120.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.20
|
| Rate for Payer: BCBS Complete |
$96.74
|
| Rate for Payer: Cash Price |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$169.29
|
| Rate for Payer: Cofinity Commercial |
$207.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$169.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.47
|
| Rate for Payer: Healthscope Commercial |
$217.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.56
|
| Rate for Payer: PHP Commercial |
$205.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.20
|
| Rate for Payer: Priority Health SBD |
$152.36
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION
|
Facility
|
OP
|
$15.15
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
17764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.06 |
| Max. Negotiated Rate |
$13.63 |
| Rate for Payer: Aetna Commercial |
$12.88
|
| Rate for Payer: Aetna Commercial |
$16.89
|
| Rate for Payer: Aetna Commercial |
$142.22
|
| Rate for Payer: Aetna Medicare |
$9.94
|
| Rate for Payer: Aetna Medicare |
$7.58
|
| Rate for Payer: Aetna Medicare |
$83.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.76
|
| Rate for Payer: BCBS Complete |
$66.93
|
| Rate for Payer: BCBS Complete |
$6.06
|
| Rate for Payer: BCBS Complete |
$7.95
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$133.86
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Cofinity Commercial |
$13.03
|
| Rate for Payer: Cofinity Commercial |
$10.61
|
| Rate for Payer: Cofinity Commercial |
$143.90
|
| Rate for Payer: Cofinity Commercial |
$117.12
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$117.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.12
|
| Rate for Payer: Healthscope Commercial |
$150.59
|
| Rate for Payer: Healthscope Commercial |
$13.63
|
| Rate for Payer: Healthscope Commercial |
$17.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.88
|
| Rate for Payer: PHP Commercial |
$142.22
|
| Rate for Payer: PHP Commercial |
$12.88
|
| Rate for Payer: PHP Commercial |
$16.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.76
|
| Rate for Payer: Priority Health SBD |
$12.52
|
| Rate for Payer: Priority Health SBD |
$105.41
|
| Rate for Payer: Priority Health SBD |
$9.54
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$167.32
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
17764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.41 |
| Max. Negotiated Rate |
$150.59 |
| Rate for Payer: Aetna Commercial |
$142.22
|
| Rate for Payer: Aetna Commercial |
$12.88
|
| Rate for Payer: Aetna Commercial |
$16.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.76
|
| Rate for Payer: Cash Price |
$133.86
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Cofinity Commercial |
$143.90
|
| Rate for Payer: Cofinity Commercial |
$13.03
|
| Rate for Payer: Cofinity Commercial |
$10.61
|
| Rate for Payer: Cofinity Commercial |
$117.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$117.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.90
|
| Rate for Payer: Healthscope Commercial |
$13.63
|
| Rate for Payer: Healthscope Commercial |
$150.59
|
| Rate for Payer: Healthscope Commercial |
$17.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.89
|
| Rate for Payer: PHP Commercial |
$12.88
|
| Rate for Payer: PHP Commercial |
$142.22
|
| Rate for Payer: PHP Commercial |
$16.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.92
|
| Rate for Payer: Priority Health SBD |
$12.52
|
| Rate for Payer: Priority Health SBD |
$9.54
|
| Rate for Payer: Priority Health SBD |
$105.41
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION
|
Facility
|
IP
|
$61.86
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.97 |
| Max. Negotiated Rate |
$55.67 |
| Rate for Payer: Aetna Commercial |
$52.58
|
| Rate for Payer: Aetna Commercial |
$340.37
|
| Rate for Payer: Aetna Commercial |
$79.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.54
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cash Price |
$74.51
|
| Rate for Payer: Cash Price |
$49.49
|
| Rate for Payer: Cofinity Commercial |
$280.31
|
| Rate for Payer: Cofinity Commercial |
$344.38
|
| Rate for Payer: Cofinity Commercial |
$43.30
|
| Rate for Payer: Cofinity Commercial |
$53.20
|
| Rate for Payer: Cofinity Commercial |
$65.20
|
| Rate for Payer: Cofinity Commercial |
$80.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$280.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.51
|
| Rate for Payer: Healthscope Commercial |
$360.40
|
| Rate for Payer: Healthscope Commercial |
$55.67
|
| Rate for Payer: Healthscope Commercial |
$83.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.17
|
| Rate for Payer: PHP Commercial |
$52.58
|
| Rate for Payer: PHP Commercial |
$79.17
|
| Rate for Payer: PHP Commercial |
$340.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.29
|
| Rate for Payer: Priority Health SBD |
$58.68
|
| Rate for Payer: Priority Health SBD |
$38.97
|
| Rate for Payer: Priority Health SBD |
$252.28
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION
|
Facility
|
OP
|
$400.44
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.18 |
| Max. Negotiated Rate |
$360.40 |
| Rate for Payer: Aetna Commercial |
$340.37
|
| Rate for Payer: Aetna Commercial |
$79.17
|
| Rate for Payer: Aetna Commercial |
$52.58
|
| Rate for Payer: Aetna Medicare |
$46.57
|
| Rate for Payer: Aetna Medicare |
$200.22
|
| Rate for Payer: Aetna Medicare |
$30.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.21
|
| Rate for Payer: BCBS Complete |
$24.74
|
| Rate for Payer: BCBS Complete |
$160.18
|
| Rate for Payer: BCBS Complete |
$37.26
|
| Rate for Payer: Cash Price |
$74.51
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cash Price |
$49.49
|
| Rate for Payer: Cofinity Commercial |
$80.10
|
| Rate for Payer: Cofinity Commercial |
$344.38
|
| Rate for Payer: Cofinity Commercial |
$280.31
|
| Rate for Payer: Cofinity Commercial |
$53.20
|
| Rate for Payer: Cofinity Commercial |
$43.30
|
| Rate for Payer: Cofinity Commercial |
$65.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$280.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.35
|
| Rate for Payer: Healthscope Commercial |
$55.67
|
| Rate for Payer: Healthscope Commercial |
$360.40
|
| Rate for Payer: Healthscope Commercial |
$83.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.37
|
| Rate for Payer: PHP Commercial |
$52.58
|
| Rate for Payer: PHP Commercial |
$340.37
|
| Rate for Payer: PHP Commercial |
$79.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.21
|
| Rate for Payer: Priority Health SBD |
$58.68
|
| Rate for Payer: Priority Health SBD |
$38.97
|
| Rate for Payer: Priority Health SBD |
$252.28
|
|
|
FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC
|
Facility
|
OP
|
$8,903.25
|
|
|
Service Code
|
CPT 30930
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,695.31 |
| Max. Negotiated Rate |
$8,903.25 |
| Rate for Payer: Aetna Medicare |
$3,289.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,953.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,953.62
|
| Rate for Payer: BCBS Complete |
$1,780.08
|
| Rate for Payer: BCBS MAPPO |
$3,162.90
|
| Rate for Payer: BCN Medicare Advantage |
$3,162.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,162.90
|
| Rate for Payer: Mclaren Medicaid |
$1,695.31
|
| Rate for Payer: Mclaren Medicare |
$3,162.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,321.05
|
| Rate for Payer: Meridian Medicaid |
$1,780.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,637.34
|
| Rate for Payer: PACE Medicare |
$3,004.76
|
| Rate for Payer: PACE SWMI |
$3,162.90
|
| Rate for Payer: PHP Medicare Advantage |
$3,162.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.31
|
| Rate for Payer: Priority Health Medicare |
$3,162.90
|
| Rate for Payer: Railroad Medicare Medicare |
$3,162.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,903.25
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,162.90
|
| Rate for Payer: UHC Medicare Advantage |
$3,162.90
|
| Rate for Payer: UHCCP Medicaid |
$1,780.71
|
| Rate for Payer: VA VA |
$3,162.90
|
|
|
FRAXEL ARMS - BILATERAL
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00166
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$663.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
FRAXEL CHEST
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00155
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$530.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
