|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$2,381.49
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$385.14 |
| Max. Negotiated Rate |
$2,381.49 |
| Rate for Payer: Aetna Medicare |
$765.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$920.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$920.51
|
| Rate for Payer: BCBS Complete |
$404.44
|
| Rate for Payer: BCBS MAPPO |
$736.41
|
| Rate for Payer: BCBS Trust/PPO |
$1,217.00
|
| Rate for Payer: BCN Commercial |
$1,217.00
|
| Rate for Payer: BCN Medicare Advantage |
$736.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$736.41
|
| Rate for Payer: Mclaren Medicaid |
$385.14
|
| Rate for Payer: Mclaren Medicare |
$736.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$773.23
|
| Rate for Payer: Meridian Medicaid |
$773.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$846.87
|
| Rate for Payer: Molina Medicare/Medicaid |
$810.05
|
| Rate for Payer: Nomi Health Commercial |
$2,209.23
|
| Rate for Payer: PACE Medicare |
$699.59
|
| Rate for Payer: PACE SWMI |
$736.41
|
| Rate for Payer: PHP Medicare Advantage |
$736.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$385.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$2,381.49
|
| Rate for Payer: Priority Health Medicare |
$736.41
|
| Rate for Payer: Priority Health Tiered Network |
$1,905.19
|
| Rate for Payer: Railroad Medicare Medicare |
$736.41
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$736.41
|
| Rate for Payer: UHC Medicaid |
$385.14
|
| Rate for Payer: UHCCP Medicaid |
$385.14
|
| Rate for Payer: VA VA |
$736.41
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$189.48
|
|
|
Service Code
|
CPT 15274
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$189.48 |
| Max. Negotiated Rate |
$189.48 |
| Rate for Payer: BCBS Trust/PPO |
$189.48
|
| Rate for Payer: BCN Commercial |
$189.48
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$6,648.46
|
|
|
Service Code
|
CPT 15273
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,075.21 |
| Max. Negotiated Rate |
$6,648.46 |
| Rate for Payer: Aetna Medicare |
$2,138.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,569.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,569.82
|
| Rate for Payer: BCBS Complete |
$1,129.08
|
| Rate for Payer: BCBS MAPPO |
$2,055.86
|
| Rate for Payer: BCBS Trust/PPO |
$1,253.77
|
| Rate for Payer: BCN Commercial |
$1,253.77
|
| Rate for Payer: BCN Medicare Advantage |
$2,055.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,055.86
|
| Rate for Payer: Mclaren Medicaid |
$1,075.21
|
| Rate for Payer: Mclaren Medicare |
$2,055.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,158.65
|
| Rate for Payer: Meridian Medicaid |
$2,158.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,364.24
|
| Rate for Payer: Molina Medicare/Medicaid |
$2,261.45
|
| Rate for Payer: Nomi Health Commercial |
$6,167.58
|
| Rate for Payer: PACE Medicare |
$1,953.07
|
| Rate for Payer: PACE SWMI |
$2,055.86
|
| Rate for Payer: PHP Medicare Advantage |
$2,055.86
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,075.21
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$6,648.46
|
| Rate for Payer: Priority Health Medicare |
$2,055.86
|
| Rate for Payer: Priority Health Tiered Network |
$5,318.77
|
| Rate for Payer: Railroad Medicare Medicare |
$2,055.86
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$2,055.86
|
| Rate for Payer: UHC Medicaid |
$1,075.21
|
| Rate for Payer: UHCCP Medicaid |
$1,075.21
|
| Rate for Payer: VA VA |
$2,055.86
|
|
|
APREPITANT 125 MG (1)-80 MG (2) CAPSULES IN A DOSE PACK
|
Facility
|
OP
|
$2,664.42
|
|
|
Service Code
|
NDC 6386203
|
| Hospital Charge Code |
35490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,047.12 |
| Max. Negotiated Rate |
$2,397.98 |
| Rate for Payer: Aetna Commercial |
$2,264.76
|
| Rate for Payer: Aetna Medicare |
$1,332.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,731.87
|
| Rate for Payer: BCBS Complete |
$1,065.77
|
| Rate for Payer: Cash Price |
$2,131.54
|
| Rate for Payer: Cofinity Advantage |
$1,865.09
|
| Rate for Payer: Cofinity Commercial |
$2,291.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,131.54
|
| Rate for Payer: Healthscope Commercial |
$2,397.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,131.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,264.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,998.32
|
| Rate for Payer: PHP Commercial |
$2,264.76
|
| Rate for Payer: Priority Health SBD |
$1,678.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,731.87
|
| Rate for Payer: UHC Core |
$1,388.16
|
| Rate for Payer: UHC Exchange |
$1,047.12
|
|
|
APREPITANT 80 MG CAPSULE
|
Facility
|
OP
|
$1,505.42
|
|
|
Service Code
|
NDC 6046102
|
| Hospital Charge Code |
35488
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$591.63 |
| Max. Negotiated Rate |
$1,354.88 |
| Rate for Payer: Aetna Commercial |
$1,279.61
|
| Rate for Payer: Aetna Medicare |
$752.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$978.52
|
| Rate for Payer: BCBS Complete |
$602.17
|
| Rate for Payer: Cash Price |
$1,204.34
|
| Rate for Payer: Cofinity Advantage |
$1,053.79
|
| Rate for Payer: Cofinity Commercial |
$1,294.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,204.34
|
| Rate for Payer: Healthscope Commercial |
$1,354.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,204.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,279.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,129.07
|
| Rate for Payer: PHP Commercial |
$1,279.61
|
| Rate for Payer: Priority Health SBD |
$948.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$978.52
|
| Rate for Payer: UHC Core |
$784.32
|
| Rate for Payer: UHC Exchange |
$591.63
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION
|
Facility
|
IP
|
$22.08
|
|
|
Service Code
|
HCPCS J7605
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.91 |
| Max. Negotiated Rate |
$19.87 |
| Rate for Payer: Aetna Commercial |
$18.77
|
| Rate for Payer: Aetna Commercial |
$13.76
|
| Rate for Payer: Aetna Commercial |
$6.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.52
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Cash Price |
$12.95
|
| Rate for Payer: Cofinity Advantage |
$15.46
|
| Rate for Payer: Cofinity Advantage |
$11.33
|
| Rate for Payer: Cofinity Advantage |
$5.60
|
| Rate for Payer: Cofinity Commercial |
$6.88
|
| Rate for Payer: Cofinity Commercial |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$18.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.40
|
| Rate for Payer: Healthscope Commercial |
$14.57
|
| Rate for Payer: Healthscope Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$7.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.56
|
| Rate for Payer: PHP Commercial |
$13.76
|
| Rate for Payer: PHP Commercial |
$6.80
|
| Rate for Payer: PHP Commercial |
$18.77
|
| Rate for Payer: Priority Health SBD |
$5.04
|
| Rate for Payer: Priority Health SBD |
$10.20
|
| Rate for Payer: Priority Health SBD |
$13.91
|
|
|
ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION
|
Facility
|
OP
|
$16.19
|
|
|
Service Code
|
HCPCS J7605
|
| Hospital Charge Code |
77581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$14.57 |
| Rate for Payer: UHC Core |
$4.17
|
| Rate for Payer: Aetna Commercial |
$13.76
|
| Rate for Payer: Aetna Commercial |
$18.77
|
| Rate for Payer: Aetna Commercial |
$6.80
|
| Rate for Payer: Aetna Medicare |
$11.04
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: Aetna Medicare |
$4.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.35
|
| Rate for Payer: BCBS Complete |
$6.48
|
| Rate for Payer: BCBS Complete |
$3.20
|
| Rate for Payer: BCBS Complete |
$8.83
|
| Rate for Payer: Cash Price |
$12.95
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cash Price |
$12.95
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Cash Price |
$17.66
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cofinity Advantage |
$11.33
|
| Rate for Payer: Cofinity Advantage |
$5.60
|
| Rate for Payer: Cofinity Advantage |
$15.46
|
| Rate for Payer: Cofinity Commercial |
$18.99
|
| Rate for Payer: Cofinity Commercial |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$6.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.40
|
| Rate for Payer: Healthscope Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$7.20
|
| Rate for Payer: Healthscope Commercial |
$14.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.56
|
| Rate for Payer: PHP Commercial |
$18.77
|
| Rate for Payer: PHP Commercial |
$13.76
|
| Rate for Payer: PHP Commercial |
$6.80
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$0.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$0.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$0.72
|
| Rate for Payer: Priority Health SBD |
$10.20
|
| Rate for Payer: Priority Health SBD |
$13.91
|
| Rate for Payer: Priority Health SBD |
$5.04
|
| Rate for Payer: Priority Health Tiered Network |
$0.58
|
| Rate for Payer: Priority Health Tiered Network |
$0.58
|
| Rate for Payer: Priority Health Tiered Network |
$0.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.52
|
| Rate for Payer: UHC Core |
$11.50
|
| Rate for Payer: UHC Core |
$8.43
|
| Rate for Payer: UHC Exchange |
$6.36
|
| Rate for Payer: UHC Exchange |
$8.68
|
| Rate for Payer: UHC Exchange |
$3.14
|
|
|
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$331.76
|
|
|
Service Code
|
HCPCS J0898
|
| Hospital Charge Code |
152708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$209.01 |
| Max. Negotiated Rate |
$298.58 |
| Rate for Payer: Aetna Commercial |
$282.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.64
|
| Rate for Payer: Cash Price |
$265.41
|
| Rate for Payer: Cofinity Advantage |
$232.23
|
| Rate for Payer: Cofinity Commercial |
$285.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.41
|
| Rate for Payer: Healthscope Commercial |
$298.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$282.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$248.82
|
| Rate for Payer: PHP Commercial |
$282.00
|
| Rate for Payer: Priority Health SBD |
$209.01
|
|
|
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$331.76
|
|
|
Service Code
|
HCPCS J0898
|
| Hospital Charge Code |
152708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$298.58 |
| Rate for Payer: Aetna Commercial |
$282.00
|
| Rate for Payer: Aetna Medicare |
$165.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.64
|
| Rate for Payer: BCBS Complete |
$132.70
|
| Rate for Payer: BCBS Trust/PPO |
$3.64
|
| Rate for Payer: BCN Commercial |
$3.64
|
| Rate for Payer: Cash Price |
$265.41
|
| Rate for Payer: Cash Price |
$265.41
|
| Rate for Payer: Cofinity Advantage |
$232.23
|
| Rate for Payer: Cofinity Commercial |
$285.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.41
|
| Rate for Payer: Healthscope Commercial |
$298.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$265.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$282.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$248.82
|
| Rate for Payer: PHP Commercial |
$282.00
|
| Rate for Payer: Priority Health SBD |
$209.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.39
|
| Rate for Payer: UHC Core |
$2.39
|
| Rate for Payer: UHC Exchange |
$2.39
|
|
|
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$432.68
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
152708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$389.41 |
| Rate for Payer: Aetna Commercial |
$367.78
|
| Rate for Payer: Aetna Commercial |
$357.92
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$281.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.26
|
| Rate for Payer: BCBS Complete |
$0.55
|
| Rate for Payer: BCBS Complete |
$0.55
|
| Rate for Payer: BCBS MAPPO |
$1.01
|
| Rate for Payer: BCBS MAPPO |
$1.01
|
| Rate for Payer: BCBS Trust/PPO |
$1.53
|
| Rate for Payer: BCBS Trust/PPO |
$1.53
|
| Rate for Payer: BCN Commercial |
$1.53
|
| Rate for Payer: BCN Commercial |
$1.53
|
| Rate for Payer: BCN Medicare Advantage |
$1.01
|
| Rate for Payer: BCN Medicare Advantage |
$1.01
|
| Rate for Payer: Cash Price |
$336.86
|
| Rate for Payer: Cash Price |
$336.86
|
| Rate for Payer: Cash Price |
$346.14
|
| Rate for Payer: Cash Price |
$346.14
|
| Rate for Payer: Cofinity Advantage |
$302.88
|
| Rate for Payer: Cofinity Advantage |
$294.76
|
| Rate for Payer: Cofinity Commercial |
$372.10
|
| Rate for Payer: Cofinity Commercial |
$362.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$346.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.01
|
| Rate for Payer: Healthscope Commercial |
$378.97
|
| Rate for Payer: Healthscope Commercial |
$389.41
|
| Rate for Payer: Mclaren Medicaid |
$0.53
|
| Rate for Payer: Mclaren Medicaid |
$0.53
|
| Rate for Payer: Mclaren Medicare |
$1.01
|
| Rate for Payer: Mclaren Medicare |
$1.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.06
|
| Rate for Payer: Meridian Medicaid |
$1.06
|
| Rate for Payer: Meridian Medicaid |
$1.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.11
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$367.78
|
| Rate for Payer: Nomi Health Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$3.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$324.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.81
|
| Rate for Payer: PACE Medicare |
$0.96
|
| Rate for Payer: PACE Medicare |
$0.96
|
| Rate for Payer: PACE SWMI |
$1.01
|
| Rate for Payer: PACE SWMI |
$1.01
|
| Rate for Payer: PHP Commercial |
$357.92
|
| Rate for Payer: PHP Commercial |
$367.78
|
| Rate for Payer: PHP Medicare Advantage |
$1.01
|
| Rate for Payer: PHP Medicare Advantage |
$1.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.53
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$2.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$2.51
|
| Rate for Payer: Priority Health Medicare |
$1.01
|
| Rate for Payer: Priority Health Medicare |
$1.01
|
| Rate for Payer: Priority Health SBD |
$272.59
|
| Rate for Payer: Priority Health SBD |
$265.28
|
| Rate for Payer: Priority Health Tiered Network |
$2.01
|
| Rate for Payer: Priority Health Tiered Network |
$2.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.01
|
| Rate for Payer: UHC Core |
$1.01
|
| Rate for Payer: UHC Core |
$1.01
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1.01
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1.01
|
| Rate for Payer: UHC Exchange |
$1.01
|
| Rate for Payer: UHC Exchange |
$1.01
|
| Rate for Payer: UHC Medicaid |
$0.53
|
| Rate for Payer: UHC Medicaid |
$0.53
|
| Rate for Payer: UHCCP Medicaid |
$0.53
|
| Rate for Payer: UHCCP Medicaid |
$0.53
|
| Rate for Payer: VA VA |
$1.01
|
| Rate for Payer: VA VA |
$1.01
|
|
|
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$432.68
|
|
|
Service Code
|
HCPCS J0883
|
| Hospital Charge Code |
152708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$272.59 |
| Max. Negotiated Rate |
$389.41 |
| Rate for Payer: Aetna Commercial |
$367.78
|
| Rate for Payer: Aetna Commercial |
$357.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$281.24
|
| Rate for Payer: Cash Price |
$336.86
|
| Rate for Payer: Cash Price |
$346.14
|
| Rate for Payer: Cofinity Advantage |
$302.88
|
| Rate for Payer: Cofinity Advantage |
$294.76
|
| Rate for Payer: Cofinity Commercial |
$362.13
|
| Rate for Payer: Cofinity Commercial |
$372.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$346.14
|
| Rate for Payer: Healthscope Commercial |
$378.97
|
| Rate for Payer: Healthscope Commercial |
$389.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$367.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$324.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.81
|
| Rate for Payer: PHP Commercial |
$357.92
|
| Rate for Payer: PHP Commercial |
$367.78
|
| Rate for Payer: Priority Health SBD |
$265.28
|
| Rate for Payer: Priority Health SBD |
$272.59
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
NDC 60687019111
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna Commercial |
$6.50
|
| Rate for Payer: Aetna Medicare |
$3.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.97
|
| Rate for Payer: BCBS Complete |
$3.06
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cofinity Advantage |
$5.36
|
| Rate for Payer: Cofinity Commercial |
$6.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.12
|
| Rate for Payer: Healthscope Commercial |
$6.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.74
|
| Rate for Payer: PHP Commercial |
$6.50
|
| Rate for Payer: Priority Health SBD |
$4.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.97
|
| Rate for Payer: UHC Core |
$3.99
|
| Rate for Payer: UHC Exchange |
$3.01
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
IP
|
$252.42
|
|
|
Service Code
|
NDC 00904736904
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.02 |
| Max. Negotiated Rate |
$227.18 |
| Rate for Payer: Aetna Commercial |
$214.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.07
|
| Rate for Payer: Cash Price |
$201.94
|
| Rate for Payer: Cofinity Advantage |
$176.69
|
| Rate for Payer: Cofinity Commercial |
$217.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.94
|
| Rate for Payer: Healthscope Commercial |
$227.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$214.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$189.31
|
| Rate for Payer: PHP Commercial |
$214.56
|
| Rate for Payer: Priority Health SBD |
$159.02
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
IP
|
$61.85
|
|
|
Service Code
|
NDC 13668021930
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.97 |
| Max. Negotiated Rate |
$55.66 |
| Rate for Payer: Aetna Commercial |
$52.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.20
|
| Rate for Payer: Cash Price |
$49.48
|
| Rate for Payer: Cofinity Advantage |
$43.30
|
| Rate for Payer: Cofinity Commercial |
$53.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.48
|
| Rate for Payer: Healthscope Commercial |
$55.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$46.39
|
| Rate for Payer: PHP Commercial |
$52.57
|
| Rate for Payer: Priority Health SBD |
$38.97
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
NDC 60687019111
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.82 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna Commercial |
$6.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.97
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cofinity Advantage |
$5.36
|
| Rate for Payer: Cofinity Commercial |
$6.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.12
|
| Rate for Payer: Healthscope Commercial |
$6.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.74
|
| Rate for Payer: PHP Commercial |
$6.50
|
| Rate for Payer: Priority Health SBD |
$4.82
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
OP
|
$229.44
|
|
|
Service Code
|
NDC 60687019121
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.17 |
| Max. Negotiated Rate |
$206.50 |
| Rate for Payer: Aetna Commercial |
$195.02
|
| Rate for Payer: Aetna Medicare |
$114.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.14
|
| Rate for Payer: BCBS Complete |
$91.78
|
| Rate for Payer: Cash Price |
$183.55
|
| Rate for Payer: Cofinity Advantage |
$160.61
|
| Rate for Payer: Cofinity Commercial |
$197.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.55
|
| Rate for Payer: Healthscope Commercial |
$206.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$183.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$172.08
|
| Rate for Payer: PHP Commercial |
$195.02
|
| Rate for Payer: Priority Health SBD |
$144.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$149.14
|
| Rate for Payer: UHC Core |
$119.54
|
| Rate for Payer: UHC Exchange |
$90.17
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
OP
|
$591.52
|
|
|
Service Code
|
NDC 00904651204
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.47 |
| Max. Negotiated Rate |
$532.37 |
| Rate for Payer: Aetna Commercial |
$502.79
|
| Rate for Payer: Aetna Medicare |
$295.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$384.49
|
| Rate for Payer: BCBS Complete |
$236.61
|
| Rate for Payer: Cash Price |
$473.22
|
| Rate for Payer: Cofinity Advantage |
$414.06
|
| Rate for Payer: Cofinity Commercial |
$508.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$473.22
|
| Rate for Payer: Healthscope Commercial |
$532.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$473.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$502.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$443.64
|
| Rate for Payer: PHP Commercial |
$502.79
|
| Rate for Payer: Priority Health SBD |
$372.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$384.49
|
| Rate for Payer: UHC Core |
$308.18
|
| Rate for Payer: UHC Exchange |
$232.47
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
IP
|
$591.52
|
|
|
Service Code
|
NDC 00904651204
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$372.66 |
| Max. Negotiated Rate |
$532.37 |
| Rate for Payer: Aetna Commercial |
$502.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$384.49
|
| Rate for Payer: Cash Price |
$473.22
|
| Rate for Payer: Cofinity Advantage |
$414.06
|
| Rate for Payer: Cofinity Commercial |
$508.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$473.22
|
| Rate for Payer: Healthscope Commercial |
$532.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$502.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$443.64
|
| Rate for Payer: PHP Commercial |
$502.79
|
| Rate for Payer: Priority Health SBD |
$372.66
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
OP
|
$252.42
|
|
|
Service Code
|
NDC 00904736904
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.20 |
| Max. Negotiated Rate |
$227.18 |
| Rate for Payer: Aetna Commercial |
$214.56
|
| Rate for Payer: Aetna Medicare |
$126.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.07
|
| Rate for Payer: BCBS Complete |
$100.97
|
| Rate for Payer: Cash Price |
$201.94
|
| Rate for Payer: Cofinity Advantage |
$176.69
|
| Rate for Payer: Cofinity Commercial |
$217.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.94
|
| Rate for Payer: Healthscope Commercial |
$227.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$201.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$214.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$189.31
|
| Rate for Payer: PHP Commercial |
$214.56
|
| Rate for Payer: Priority Health SBD |
$159.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$164.07
|
| Rate for Payer: UHC Core |
$131.51
|
| Rate for Payer: UHC Exchange |
$99.20
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
OP
|
$61.85
|
|
|
Service Code
|
NDC 13668021930
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.31 |
| Max. Negotiated Rate |
$55.66 |
| Rate for Payer: Aetna Commercial |
$52.57
|
| Rate for Payer: Aetna Medicare |
$30.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.20
|
| Rate for Payer: BCBS Complete |
$24.74
|
| Rate for Payer: Cash Price |
$49.48
|
| Rate for Payer: Cofinity Advantage |
$43.30
|
| Rate for Payer: Cofinity Commercial |
$53.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.48
|
| Rate for Payer: Healthscope Commercial |
$55.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$49.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$46.39
|
| Rate for Payer: PHP Commercial |
$52.57
|
| Rate for Payer: Priority Health SBD |
$38.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.20
|
| Rate for Payer: UHC Core |
$32.22
|
| Rate for Payer: UHC Exchange |
$24.31
|
|
|
ARIPIPRAZOLE 15 MG TABLET
|
Facility
|
IP
|
$229.44
|
|
|
Service Code
|
NDC 60687019121
|
| Hospital Charge Code |
34370
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.55 |
| Max. Negotiated Rate |
$206.50 |
| Rate for Payer: Aetna Commercial |
$195.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.14
|
| Rate for Payer: Cash Price |
$183.55
|
| Rate for Payer: Cofinity Advantage |
$160.61
|
| Rate for Payer: Cofinity Commercial |
$197.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.55
|
| Rate for Payer: Healthscope Commercial |
$206.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$172.08
|
| Rate for Payer: PHP Commercial |
$195.02
|
| Rate for Payer: Priority Health SBD |
$144.55
|
|
|
ARIPIPRAZOLE 2 MG TABLET
|
Facility
|
OP
|
$57.57
|
|
|
Service Code
|
NDC 65162089603
|
| Hospital Charge Code |
70306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.63 |
| Max. Negotiated Rate |
$51.81 |
| Rate for Payer: Aetna Commercial |
$48.93
|
| Rate for Payer: Aetna Medicare |
$28.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.42
|
| Rate for Payer: BCBS Complete |
$23.03
|
| Rate for Payer: Cash Price |
$46.06
|
| Rate for Payer: Cofinity Advantage |
$40.30
|
| Rate for Payer: Cofinity Commercial |
$49.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.06
|
| Rate for Payer: Healthscope Commercial |
$51.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$46.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.18
|
| Rate for Payer: PHP Commercial |
$48.93
|
| Rate for Payer: Priority Health SBD |
$36.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.42
|
| Rate for Payer: UHC Core |
$29.99
|
| Rate for Payer: UHC Exchange |
$22.63
|
|
|
ARIPIPRAZOLE 2 MG TABLET
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 50268008711
|
| Hospital Charge Code |
70306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.77
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cofinity Advantage |
$2.98
|
| Rate for Payer: Cofinity Commercial |
$3.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.41
|
| Rate for Payer: Healthscope Commercial |
$3.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.19
|
| Rate for Payer: PHP Commercial |
$3.62
|
| Rate for Payer: Priority Health SBD |
$2.68
|
|
|
ARIPIPRAZOLE 2 MG TABLET
|
Facility
|
IP
|
$61.28
|
|
|
Service Code
|
NDC 67877043003
|
| Hospital Charge Code |
70306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.61 |
| Max. Negotiated Rate |
$55.15 |
| Rate for Payer: Aetna Commercial |
$52.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.83
|
| Rate for Payer: Cash Price |
$49.02
|
| Rate for Payer: Cofinity Advantage |
$42.90
|
| Rate for Payer: Cofinity Commercial |
$52.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.02
|
| Rate for Payer: Healthscope Commercial |
$55.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.96
|
| Rate for Payer: PHP Commercial |
$52.09
|
| Rate for Payer: Priority Health SBD |
$38.61
|
|
|
ARIPIPRAZOLE 2 MG TABLET
|
Facility
|
IP
|
$200.31
|
|
|
Service Code
|
NDC 60505307503
|
| Hospital Charge Code |
70306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.20 |
| Max. Negotiated Rate |
$180.28 |
| Rate for Payer: Aetna Commercial |
$170.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.20
|
| Rate for Payer: Cash Price |
$160.25
|
| Rate for Payer: Cofinity Advantage |
$140.22
|
| Rate for Payer: Cofinity Commercial |
$172.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.25
|
| Rate for Payer: Healthscope Commercial |
$180.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$150.23
|
| Rate for Payer: PHP Commercial |
$170.26
|
| Rate for Payer: Priority Health SBD |
$126.20
|
|
