|
BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES
|
Facility
OP
|
$9,644.80
|
|
|
Service Code
|
CPT 31653
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$234.12 |
| Max. Negotiated Rate |
$9,644.80 |
| Rate for Payer: Aetna Medicare |
$3,465.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,165.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,165.16
|
| Rate for Payer: BCBS Complete |
$1,913.98
|
| Rate for Payer: BCBS MAPPO |
$3,332.13
|
| Rate for Payer: BCBS Trust/PPO |
$2,854.68
|
| Rate for Payer: BCN Medicare Advantage |
$3,332.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,332.13
|
| Rate for Payer: Mclaren Medicaid |
$1,822.68
|
| Rate for Payer: Mclaren Medicare |
$3,332.13
|
| Rate for Payer: Meridian Medicaid |
$1,913.98
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,498.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,831.95
|
| Rate for Payer: PACE Medicare |
$3,165.52
|
| Rate for Payer: PACE SWMI |
$3,332.13
|
| Rate for Payer: PHP Medicare Advantage |
$3,332.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,822.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,644.80
|
| Rate for Payer: Priority Health Medicare |
$3,332.13
|
| Rate for Payer: Priority Health Narrow Network |
$7,715.84
|
| Rate for Payer: Railroad Medicare Medicare |
$3,332.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.53
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,332.13
|
| Rate for Payer: UHC Exchange |
$234.12
|
| Rate for Payer: UHC Medicare Advantage |
$3,432.09
|
| Rate for Payer: VA VA |
$3,332.13
|
|
|
BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES
|
Facility
OP
|
$9,644.80
|
|
|
Service Code
|
CPT 31652
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$211.20 |
| Max. Negotiated Rate |
$9,644.80 |
| Rate for Payer: Aetna Medicare |
$3,465.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,165.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,165.16
|
| Rate for Payer: BCBS Complete |
$1,913.98
|
| Rate for Payer: BCBS MAPPO |
$3,332.13
|
| Rate for Payer: BCBS Trust/PPO |
$2,533.06
|
| Rate for Payer: BCN Medicare Advantage |
$3,332.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,332.13
|
| Rate for Payer: Mclaren Medicaid |
$1,822.68
|
| Rate for Payer: Mclaren Medicare |
$3,332.13
|
| Rate for Payer: Meridian Medicaid |
$1,913.98
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,498.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,831.95
|
| Rate for Payer: PACE Medicare |
$3,165.52
|
| Rate for Payer: PACE SWMI |
$3,332.13
|
| Rate for Payer: PHP Medicare Advantage |
$3,332.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,822.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,644.80
|
| Rate for Payer: Priority Health Medicare |
$3,332.13
|
| Rate for Payer: Priority Health Narrow Network |
$7,715.84
|
| Rate for Payer: Railroad Medicare Medicare |
$3,332.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$232.32
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,332.13
|
| Rate for Payer: UHC Exchange |
$211.20
|
| Rate for Payer: UHC Medicare Advantage |
$3,432.09
|
| Rate for Payer: VA VA |
$3,332.13
|
|
|
BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL
|
Facility
OP
|
$4,658.40
|
|
|
Service Code
|
CPT 31645
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$141.45 |
| Max. Negotiated Rate |
$4,658.40 |
| Rate for Payer: Aetna Medicare |
$1,570.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,887.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,887.76
|
| Rate for Payer: BCBS Complete |
$867.46
|
| Rate for Payer: BCBS MAPPO |
$1,510.21
|
| Rate for Payer: BCBS Trust/PPO |
$576.47
|
| Rate for Payer: BCN Medicare Advantage |
$1,510.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,510.21
|
| Rate for Payer: Mclaren Medicaid |
$826.08
|
| Rate for Payer: Mclaren Medicare |
$1,510.21
|
| Rate for Payer: Meridian Medicaid |
$867.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,585.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,736.74
|
| Rate for Payer: PACE Medicare |
$1,434.70
|
| Rate for Payer: PACE SWMI |
$1,510.21
|
| Rate for Payer: PHP Medicare Advantage |
$1,510.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$826.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,658.40
|
| Rate for Payer: Priority Health Medicare |
$1,510.21
|
| Rate for Payer: Priority Health Narrow Network |
$3,726.72
|
| Rate for Payer: Railroad Medicare Medicare |
$1,510.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$155.60
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,510.21
|
| Rate for Payer: UHC Exchange |
$141.45
|
| Rate for Payer: UHC Medicare Advantage |
$1,555.52
|
| Rate for Payer: VA VA |
$1,510.21
|
|
|
BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE
|
Facility
OP
|
$9,644.80
|
|
|
Service Code
|
CPT 31628
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$168.63 |
| Max. Negotiated Rate |
$9,644.80 |
| Rate for Payer: Aetna Medicare |
$3,465.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,165.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,165.16
|
| Rate for Payer: BCBS Complete |
$1,913.98
|
| Rate for Payer: BCBS MAPPO |
$3,332.13
|
| Rate for Payer: BCBS Trust/PPO |
$1,036.43
|
| Rate for Payer: BCN Medicare Advantage |
$3,332.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,332.13
|
| Rate for Payer: Mclaren Medicaid |
$1,822.68
|
| Rate for Payer: Mclaren Medicare |
$3,332.13
|
| Rate for Payer: Meridian Medicaid |
$1,913.98
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,498.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,831.95
|
| Rate for Payer: PACE Medicare |
$3,165.52
|
| Rate for Payer: PACE SWMI |
$3,332.13
|
| Rate for Payer: PHP Medicare Advantage |
$3,332.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,822.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,644.80
|
| Rate for Payer: Priority Health Medicare |
$3,332.13
|
| Rate for Payer: Priority Health Narrow Network |
$7,715.84
|
| Rate for Payer: Railroad Medicare Medicare |
$3,332.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$185.49
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,332.13
|
| Rate for Payer: UHC Exchange |
$168.63
|
| Rate for Payer: UHC Medicare Advantage |
$3,432.09
|
| Rate for Payer: VA VA |
$3,332.13
|
|
|
BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)
|
Facility
OP
|
$9,644.80
|
|
|
Service Code
|
CPT 31629
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$179.11 |
| Max. Negotiated Rate |
$9,644.80 |
| Rate for Payer: Aetna Medicare |
$3,465.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,165.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,165.16
|
| Rate for Payer: BCBS Complete |
$1,913.98
|
| Rate for Payer: BCBS MAPPO |
$3,332.13
|
| Rate for Payer: BCBS Trust/PPO |
$1,569.18
|
| Rate for Payer: BCN Medicare Advantage |
$3,332.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,332.13
|
| Rate for Payer: Mclaren Medicaid |
$1,822.68
|
| Rate for Payer: Mclaren Medicare |
$3,332.13
|
| Rate for Payer: Meridian Medicaid |
$1,913.98
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,498.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,831.95
|
| Rate for Payer: PACE Medicare |
$3,165.52
|
| Rate for Payer: PACE SWMI |
$3,332.13
|
| Rate for Payer: PHP Medicare Advantage |
$3,332.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,822.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,644.80
|
| Rate for Payer: Priority Health Medicare |
$3,332.13
|
| Rate for Payer: Priority Health Narrow Network |
$7,715.84
|
| Rate for Payer: Railroad Medicare Medicare |
$3,332.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$197.02
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,332.13
|
| Rate for Payer: UHC Exchange |
$179.11
|
| Rate for Payer: UHC Medicare Advantage |
$3,432.09
|
| Rate for Payer: VA VA |
$3,332.13
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION
|
Facility
IP
|
$9.49
|
|
|
Service Code
|
HCPCS J7626
|
| Hospital Charge Code |
28774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.98 |
| Max. Negotiated Rate |
$8.54 |
| Rate for Payer: Aetna Commercial |
$8.07
|
| Rate for Payer: Aetna Commercial |
$25.47
|
| Rate for Payer: Aetna Commercial |
$7.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.47
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Cash Price |
$23.97
|
| Rate for Payer: Cofinity Commercial |
$8.16
|
| Rate for Payer: Cofinity Commercial |
$25.77
|
| Rate for Payer: Cofinity Commercial |
$6.01
|
| Rate for Payer: Cofinity Commercial |
$7.39
|
| Rate for Payer: Cofinity Commercial |
$6.64
|
| Rate for Payer: Cofinity Commercial |
$20.97
|
| Rate for Payer: Healthscope Commercial |
$7.73
|
| Rate for Payer: Healthscope Commercial |
$26.96
|
| Rate for Payer: Healthscope Commercial |
$8.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.47
|
| Rate for Payer: PHP Commercial |
$8.07
|
| Rate for Payer: PHP Commercial |
$25.47
|
| Rate for Payer: PHP Commercial |
$7.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.64
|
| Rate for Payer: Priority Health SBD |
$5.41
|
| Rate for Payer: Priority Health SBD |
$18.87
|
| Rate for Payer: Priority Health SBD |
$5.98
|
|
|
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION
|
Facility
IP
|
$12.10
|
|
|
Service Code
|
HCPCS J7626
|
| Hospital Charge Code |
28775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.62 |
| Max. Negotiated Rate |
$10.89 |
| Rate for Payer: Aetna Commercial |
$10.28
|
| Rate for Payer: Aetna Commercial |
$8.73
|
| Rate for Payer: Aetna Commercial |
$11.60
|
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: Aetna Commercial |
$29.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.87
|
| Rate for Payer: Cash Price |
$8.22
|
| Rate for Payer: Cash Price |
$28.22
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cash Price |
$6.31
|
| Rate for Payer: Cash Price |
$9.68
|
| Rate for Payer: Cofinity Commercial |
$30.33
|
| Rate for Payer: Cofinity Commercial |
$24.69
|
| Rate for Payer: Cofinity Commercial |
$9.56
|
| Rate for Payer: Cofinity Commercial |
$5.52
|
| Rate for Payer: Cofinity Commercial |
$8.83
|
| Rate for Payer: Cofinity Commercial |
$6.79
|
| Rate for Payer: Cofinity Commercial |
$10.41
|
| Rate for Payer: Cofinity Commercial |
$8.47
|
| Rate for Payer: Cofinity Commercial |
$11.74
|
| Rate for Payer: Cofinity Commercial |
$7.19
|
| Rate for Payer: Healthscope Commercial |
$31.74
|
| Rate for Payer: Healthscope Commercial |
$9.24
|
| Rate for Payer: Healthscope Commercial |
$10.89
|
| Rate for Payer: Healthscope Commercial |
$12.28
|
| Rate for Payer: Healthscope Commercial |
$7.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.28
|
| Rate for Payer: PHP Commercial |
$29.98
|
| Rate for Payer: PHP Commercial |
$6.71
|
| Rate for Payer: PHP Commercial |
$10.28
|
| Rate for Payer: PHP Commercial |
$11.60
|
| Rate for Payer: PHP Commercial |
$8.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.69
|
| Rate for Payer: Priority Health SBD |
$6.47
|
| Rate for Payer: Priority Health SBD |
$7.62
|
| Rate for Payer: Priority Health SBD |
$22.22
|
| Rate for Payer: Priority Health SBD |
$8.60
|
| Rate for Payer: Priority Health SBD |
$4.97
|
|
|
BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE
|
Facility
IP
|
$312.96
|
|
|
Service Code
|
NDC 65162-778-10
|
| Hospital Charge Code |
31576
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.16 |
| Max. Negotiated Rate |
$281.66 |
| Rate for Payer: Aetna Commercial |
$266.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.42
|
| Rate for Payer: Cash Price |
$250.37
|
| Rate for Payer: Cofinity Commercial |
$219.07
|
| Rate for Payer: Cofinity Commercial |
$269.15
|
| Rate for Payer: Healthscope Commercial |
$281.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$266.02
|
| Rate for Payer: PHP Commercial |
$266.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.07
|
| Rate for Payer: Priority Health SBD |
$197.16
|
|
|
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL COMMON CANISTER INHALER
|
Facility
IP
|
$96.60
|
|
|
Service Code
|
NDC 0186-0370-28
|
| Hospital Charge Code |
300057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.86 |
| Max. Negotiated Rate |
$86.94 |
| Rate for Payer: Aetna Commercial |
$82.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.79
|
| Rate for Payer: Cash Price |
$77.28
|
| Rate for Payer: Cofinity Commercial |
$67.62
|
| Rate for Payer: Cofinity Commercial |
$83.08
|
| Rate for Payer: Healthscope Commercial |
$86.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.11
|
| Rate for Payer: PHP Commercial |
$82.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.62
|
| Rate for Payer: Priority Health SBD |
$60.86
|
|
|
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER
|
Facility
IP
|
$96.60
|
|
|
Service Code
|
NDC 0186-0370-28
|
| Hospital Charge Code |
81454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.86 |
| Max. Negotiated Rate |
$86.94 |
| Rate for Payer: Aetna Commercial |
$82.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.79
|
| Rate for Payer: Cash Price |
$77.28
|
| Rate for Payer: Cofinity Commercial |
$67.62
|
| Rate for Payer: Cofinity Commercial |
$83.08
|
| Rate for Payer: Healthscope Commercial |
$86.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.11
|
| Rate for Payer: PHP Commercial |
$82.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.62
|
| Rate for Payer: Priority Health SBD |
$60.86
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL COMMON CANISTER INHALER
|
Facility
IP
|
$193.41
|
|
|
Service Code
|
NDC 0186-0372-28
|
| Hospital Charge Code |
300059
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.85 |
| Max. Negotiated Rate |
$174.07 |
| Rate for Payer: Aetna Commercial |
$164.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.72
|
| Rate for Payer: Cash Price |
$154.73
|
| Rate for Payer: Cofinity Commercial |
$135.39
|
| Rate for Payer: Cofinity Commercial |
$166.33
|
| Rate for Payer: Healthscope Commercial |
$174.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$164.40
|
| Rate for Payer: PHP Commercial |
$164.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.39
|
| Rate for Payer: Priority Health SBD |
$121.85
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER
|
Facility
IP
|
$193.41
|
|
|
Service Code
|
NDC 0186-0372-28
|
| Hospital Charge Code |
81453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.85 |
| Max. Negotiated Rate |
$174.07 |
| Rate for Payer: Aetna Commercial |
$164.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.72
|
| Rate for Payer: Cash Price |
$154.73
|
| Rate for Payer: Cofinity Commercial |
$135.39
|
| Rate for Payer: Cofinity Commercial |
$166.33
|
| Rate for Payer: Healthscope Commercial |
$174.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$164.40
|
| Rate for Payer: PHP Commercial |
$164.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.39
|
| Rate for Payer: Priority Health SBD |
$121.85
|
|
|
BUFFERED LIDOCAINE 1% WITH EPI
|
Facility
IP
|
$20.87
|
|
|
Service Code
|
NDC 9900-0010-74
|
| Hospital Charge Code |
500548
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.15 |
| Max. Negotiated Rate |
$18.78 |
| Rate for Payer: Aetna Commercial |
$17.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.57
|
| Rate for Payer: Cash Price |
$16.70
|
| Rate for Payer: Cofinity Commercial |
$14.61
|
| Rate for Payer: Cofinity Commercial |
$17.95
|
| Rate for Payer: Healthscope Commercial |
$18.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.74
|
| Rate for Payer: PHP Commercial |
$17.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.61
|
| Rate for Payer: Priority Health SBD |
$13.15
|
|
|
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION
|
Facility
IP
|
$25.76
|
|
|
Service Code
|
HCPCS J1939
|
| Hospital Charge Code |
9308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.23 |
| Max. Negotiated Rate |
$23.18 |
| Rate for Payer: Aetna Commercial |
$21.90
|
| Rate for Payer: Aetna Commercial |
$15.72
|
| Rate for Payer: Aetna Commercial |
$18.89
|
| Rate for Payer: Aetna Commercial |
$19.57
|
| Rate for Payer: Aetna Commercial |
$21.69
|
| Rate for Payer: Aetna Commercial |
$23.54
|
| Rate for Payer: Aetna Commercial |
$23.79
|
| Rate for Payer: Aetna Commercial |
$24.36
|
| Rate for Payer: Aetna Commercial |
$24.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.63
|
| Rate for Payer: Cash Price |
$22.93
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cash Price |
$20.42
|
| Rate for Payer: Cash Price |
$18.42
|
| Rate for Payer: Cash Price |
$22.16
|
| Rate for Payer: Cash Price |
$14.80
|
| Rate for Payer: Cash Price |
$20.61
|
| Rate for Payer: Cash Price |
$22.39
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cofinity Commercial |
$22.15
|
| Rate for Payer: Cofinity Commercial |
$19.39
|
| Rate for Payer: Cofinity Commercial |
$15.55
|
| Rate for Payer: Cofinity Commercial |
$24.65
|
| Rate for Payer: Cofinity Commercial |
$19.59
|
| Rate for Payer: Cofinity Commercial |
$15.91
|
| Rate for Payer: Cofinity Commercial |
$24.74
|
| Rate for Payer: Cofinity Commercial |
$16.11
|
| Rate for Payer: Cofinity Commercial |
$19.80
|
| Rate for Payer: Cofinity Commercial |
$24.07
|
| Rate for Payer: Cofinity Commercial |
$20.14
|
| Rate for Payer: Cofinity Commercial |
$20.06
|
| Rate for Payer: Cofinity Commercial |
$17.86
|
| Rate for Payer: Cofinity Commercial |
$21.95
|
| Rate for Payer: Cofinity Commercial |
$19.11
|
| Rate for Payer: Cofinity Commercial |
$23.82
|
| Rate for Payer: Cofinity Commercial |
$18.03
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Healthscope Commercial |
$16.65
|
| Rate for Payer: Healthscope Commercial |
$25.19
|
| Rate for Payer: Healthscope Commercial |
$20.00
|
| Rate for Payer: Healthscope Commercial |
$25.89
|
| Rate for Payer: Healthscope Commercial |
$20.72
|
| Rate for Payer: Healthscope Commercial |
$22.97
|
| Rate for Payer: Healthscope Commercial |
$23.18
|
| Rate for Payer: Healthscope Commercial |
$25.79
|
| Rate for Payer: Healthscope Commercial |
$24.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.90
|
| Rate for Payer: PHP Commercial |
$21.69
|
| Rate for Payer: PHP Commercial |
$18.89
|
| Rate for Payer: PHP Commercial |
$15.72
|
| Rate for Payer: PHP Commercial |
$19.57
|
| Rate for Payer: PHP Commercial |
$21.90
|
| Rate for Payer: PHP Commercial |
$23.54
|
| Rate for Payer: PHP Commercial |
$23.79
|
| Rate for Payer: PHP Commercial |
$24.36
|
| Rate for Payer: PHP Commercial |
$24.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.86
|
| Rate for Payer: Priority Health SBD |
$17.45
|
| Rate for Payer: Priority Health SBD |
$16.23
|
| Rate for Payer: Priority Health SBD |
$16.08
|
| Rate for Payer: Priority Health SBD |
$18.06
|
| Rate for Payer: Priority Health SBD |
$11.66
|
| Rate for Payer: Priority Health SBD |
$14.50
|
| Rate for Payer: Priority Health SBD |
$14.00
|
| Rate for Payer: Priority Health SBD |
$17.63
|
| Rate for Payer: Priority Health SBD |
$18.13
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$4.14
|
|
|
Service Code
|
NDC 50268-131-11
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.69
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cofinity Commercial |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.56
|
| Rate for Payer: Healthscope Commercial |
$3.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.52
|
| Rate for Payer: PHP Commercial |
$3.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.90
|
| Rate for Payer: Priority Health SBD |
$2.61
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$176.16
|
|
|
Service Code
|
NDC 0904-7016-06
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.98 |
| Max. Negotiated Rate |
$158.54 |
| Rate for Payer: Aetna Commercial |
$149.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.50
|
| Rate for Payer: Cash Price |
$140.93
|
| Rate for Payer: Cofinity Commercial |
$123.31
|
| Rate for Payer: Cofinity Commercial |
$151.50
|
| Rate for Payer: Healthscope Commercial |
$158.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$149.74
|
| Rate for Payer: PHP Commercial |
$149.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.31
|
| Rate for Payer: Priority Health SBD |
$110.98
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$400.90
|
|
|
Service Code
|
NDC 0185-0129-01
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$252.57 |
| Max. Negotiated Rate |
$360.81 |
| Rate for Payer: Aetna Commercial |
$340.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.58
|
| Rate for Payer: Cash Price |
$320.72
|
| Rate for Payer: Cofinity Commercial |
$280.63
|
| Rate for Payer: Cofinity Commercial |
$344.77
|
| Rate for Payer: Healthscope Commercial |
$360.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$340.76
|
| Rate for Payer: PHP Commercial |
$340.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$280.63
|
| Rate for Payer: Priority Health SBD |
$252.57
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$448.85
|
|
|
Service Code
|
NDC 69238-1490-1
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$282.78 |
| Max. Negotiated Rate |
$403.96 |
| Rate for Payer: Aetna Commercial |
$381.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.75
|
| Rate for Payer: Cash Price |
$359.08
|
| Rate for Payer: Cofinity Commercial |
$314.20
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Healthscope Commercial |
$403.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$381.52
|
| Rate for Payer: PHP Commercial |
$381.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$314.20
|
| Rate for Payer: Priority Health SBD |
$282.78
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$2,004.50
|
|
|
Service Code
|
NDC 0185-0129-05
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,262.84 |
| Max. Negotiated Rate |
$1,804.05 |
| Rate for Payer: Aetna Commercial |
$1,703.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,302.92
|
| Rate for Payer: Cash Price |
$1,603.60
|
| Rate for Payer: Cofinity Commercial |
$1,403.15
|
| Rate for Payer: Cofinity Commercial |
$1,723.87
|
| Rate for Payer: Healthscope Commercial |
$1,804.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,703.82
|
| Rate for Payer: PHP Commercial |
$1,703.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,403.15
|
| Rate for Payer: Priority Health SBD |
$1,262.84
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$206.64
|
|
|
Service Code
|
NDC 50268-131-15
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.18 |
| Max. Negotiated Rate |
$185.98 |
| Rate for Payer: Aetna Commercial |
$175.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.32
|
| Rate for Payer: Cash Price |
$165.31
|
| Rate for Payer: Cofinity Commercial |
$144.65
|
| Rate for Payer: Cofinity Commercial |
$177.71
|
| Rate for Payer: Healthscope Commercial |
$185.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.64
|
| Rate for Payer: PHP Commercial |
$175.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.65
|
| Rate for Payer: Priority Health SBD |
$130.18
|
|
|
BUMETANIDE 2 MG TABLET
|
Facility
IP
|
$416.10
|
|
|
Service Code
|
NDC 69238-1491-1
|
| Hospital Charge Code |
9311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.14 |
| Max. Negotiated Rate |
$374.49 |
| Rate for Payer: Aetna Commercial |
$353.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$270.46
|
| Rate for Payer: Cash Price |
$332.88
|
| Rate for Payer: Cofinity Commercial |
$291.27
|
| Rate for Payer: Cofinity Commercial |
$357.85
|
| Rate for Payer: Healthscope Commercial |
$374.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$353.68
|
| Rate for Payer: PHP Commercial |
$353.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.27
|
| Rate for Payer: Priority Health SBD |
$262.14
|
|
|
BUMETANIDE 2 MG TABLET
|
Facility
IP
|
$6.59
|
|
|
Service Code
|
NDC 60687-535-11
|
| Hospital Charge Code |
9311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.15 |
| Max. Negotiated Rate |
$5.93 |
| Rate for Payer: Aetna Commercial |
$5.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.28
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cofinity Commercial |
$4.61
|
| Rate for Payer: Cofinity Commercial |
$5.67
|
| Rate for Payer: Healthscope Commercial |
$5.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.60
|
| Rate for Payer: PHP Commercial |
$5.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.61
|
| Rate for Payer: Priority Health SBD |
$4.15
|
|
|
BUMETANIDE 2 MG TABLET
|
Facility
IP
|
$658.56
|
|
|
Service Code
|
NDC 60687-535-01
|
| Hospital Charge Code |
9311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$414.89 |
| Max. Negotiated Rate |
$592.70 |
| Rate for Payer: Aetna Commercial |
$559.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$428.06
|
| Rate for Payer: Cash Price |
$526.85
|
| Rate for Payer: Cofinity Commercial |
$460.99
|
| Rate for Payer: Cofinity Commercial |
$566.36
|
| Rate for Payer: Healthscope Commercial |
$592.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$559.78
|
| Rate for Payer: PHP Commercial |
$559.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$460.99
|
| Rate for Payer: Priority Health SBD |
$414.89
|
|
|
BUMETANIDE 2 MG TABLET
|
Facility
IP
|
$375.84
|
|
|
Service Code
|
NDC 0185-0130-01
|
| Hospital Charge Code |
9311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$236.78 |
| Max. Negotiated Rate |
$338.26 |
| Rate for Payer: Aetna Commercial |
$319.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$244.30
|
| Rate for Payer: Cash Price |
$300.67
|
| Rate for Payer: Cofinity Commercial |
$263.09
|
| Rate for Payer: Cofinity Commercial |
$323.22
|
| Rate for Payer: Healthscope Commercial |
$338.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$319.46
|
| Rate for Payer: PHP Commercial |
$319.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.09
|
| Rate for Payer: Priority Health SBD |
$236.78
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$21.94
|
|
|
Service Code
|
NDC 9900-0018-97
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.82 |
| Max. Negotiated Rate |
$19.75 |
| Rate for Payer: Aetna Commercial |
$18.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.26
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cofinity Commercial |
$15.36
|
| Rate for Payer: Cofinity Commercial |
$18.87
|
| Rate for Payer: Healthscope Commercial |
$19.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.65
|
| Rate for Payer: PHP Commercial |
$18.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.36
|
| Rate for Payer: Priority Health SBD |
$13.82
|
|
